c) ABBOTT

The Morphology of
Human Blood Cells
DIGGS
STURM
BELL

FIFTH EDITION
 Digitized by the Internet Archive
In 2024

https://archive.org/details/ison_0125397151
The Morphology
of
Human Blood Cells

L. W. Diggs, MD; Dorothy Sturm; and Ann Bell, MS

University of Tennessee Center for Health Sciences
Department of Medicine, Division of Hematology
and Regional Medical Center
Memphis, Tennessee

FIFTH EDITION

ABBOTT LABORATORIES
Abbott Park, IL 60064
Copyright © 1985, 1984, 1978, 1975, 1970 by Abbott Laboratories. All rights reserved. Printed in the United
States of America. No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior
permission of the publisher.
CONTENTS

CELL MORPHOLOGY
— GENERAL
Maturation sequence
Reproductive sequence
Nomenclature

LEUKOCYTES, ERYTHROCYTES, THROMBOCYTES

Neutrophilic leukocytes
Eosinophils
Basophils
Monocytes
Lymphocytes
Plasmocytes
Erythrocytes
Megakaryocytes and thrombocytes

TISSUE CELLS
Stem cells
Tissue granulocytes
Macrophages
Fat cells
Bone cells
Fibrocytes
Endothelial cells

PATHOLOGICAL ERYTHROCYTES

PATHOLOGICAL LEUKOCYTES AND THROMBOCYTES

INDEX

Vil. ORIGIN AND DEVELOPMENT OF BLOOD CELLS (FOLDOUT)

PREFACE

This atlas, which portrays the morphologic characteristics differential diagnosis of various diseases, the establishment
of normal and pathologic cells in smears of blood and bone of prognosis, the indications for treatment, and the response
marrow, is published mainly for the use of medical students, to therapy—and as a safeguard against drug toxicity.
student medical technologists, veterinary students, and other The development of new instruments and new technologies
health-science students who are learning to identify the such as electron, stereoscan, and fluorescent microscopy and
various types of hemic cells. This monograph also is an aid the employment of cytochemical, enzymatic, radioisotopic,
for teachers of morphologic hematology and for technologists centrifugal, serologic, electrophoretic, and other procedures
and technicians who are responsible for the examination of have expanded our knowledge and understanding of normal
smears by manual or automated methods and for the and pathophysiologic mechanisms and the interpretation of
reporting of differential counts. A knowledge of morphology morphologic characteristics as revealed by optical micro-
is also useful for residents in clinical and anatomic pathology, scopy. These new, ingenious, important, and welcomed tech-
pediatrics, and medicine. niques are supplements to—not replacements of—the simple,
Major emphasis is placed on the anatomical characteristics time-honored, and relatively inexpensive microscopic
of individual cells in the various stages of their maturation procedures.
as revealed by light microscopy, employing an oil-immersion The reader is referred to textbooks of hematology for a
objective. Unless otherwise stated, the cells that are described discussion of etiologic factors, the clinical and anatomical
and visually depicted by the artist, Dorothy Sturm, are those manifestations, and the treatment of various diseases of blood
present in thin, air-exposed, dried smears or imprints that and blood-forming organs. The reader is also referred to other
have been stained by a combination (Wright or equivalent sources for information about techniques, cell kinetics, patho-
stain) of the blue dye (methylene blue) and the red dye (eosin). physiology, and lists of diseases characterized by an increase
The procedure was to select an ideally prepared stained or decrease in the total leukocyte count and in the relative
smear of fresh blood or aspirate of bone marrow without and absolute numbers of nucleated cells of different types.
admixture with an anticoagulant and without fixation except Appreciation is expressed to numerous individuals who
by air drying and by methy] alcohol in the stain—and then assisted in various ways in the preparation of this atlas. These
to locate a typical cell in the thin portion of asmear. Dorothy include Mrs. Jane Tyler and other technologists in the special
Sturm, a skilled artist as well as a biologically trained scientist, hematology laboratory at Baptist Memorial Hospital; Mrs.
painted the various colors and structures of the cells as she Lew Bailey and Mrs. Linda Mason, medical technologists
viewed them. Water colors were employed for the color plates. at the Regional Medical Center; Mrs. Sara Cobb at St. Jude
It is impossible to portray by means of a relatively few Children’s Research Hospital—and from the University of
cells all the infinite variations of nuclear and cytoplasmic Tennessee Center for the Health Sciences, Division of
structures of normal and pathologic cells. The authors have Hematology, Miss Helen Goodman, a hematology tech-
attempted to portray cells that are representative. Once nologist; Miss Jeanie Peeples, research technician; and Drs.
selected, the cell was painted as that individual cell appeared. Luther Burkett, Marion Dugdale, Henry Herrod, Alfred
Unless otherwise specified, all cells are reproduced at a magni- Kraus, Alvin Mauer, Charles Neely, Gerald Plitman, and J.D.
fication of approximately x 1,800. Upshaw. The authors wish to thank Mrs. Beatrice Diggs for
The microscopic examination ofthe cells of the blood and library work, editing, and typing; Mr. Thomas Craig, from
blood-forming organs is an extension of the history and Abbott Laboratories professional relations, for his cooper-
physical examination. The identification and enumeration ation and understanding in the technical phases ofthe editing
of cells in stained smears is of value as a screening procedure and printing; and Abbott Laboratories for publishing this
to detect normality as well as an aid in the diagnosis and atlas as a service to the medical profession.

L. W. Diggs, MD

il
 B C

PLATE 1—MATURATION SEQUENCE

A Cell size and cytoplasm color
B Nuclear size and color
C Nuclear chromatin structure
D Composite (Top to bottom: Rubriblast,
prorubricyte, rubricyte, metarubricyte, diffusely
basophilic erythrocyte, erythrocyte)

lv
CELL MORPHOLOGY — GENERAL

A. BLOOD CELLS originate from undifferentiated mes- of aspiration or spreading ona slide, the delicate and lacelike
enchymal cells (Table 1, Fig 20). From these stem cells, clones chromatin strands become thick and ropy but remain intact
of cells differentiate and ultimately appear in the circulating and distinct. When the nucleus degenerates, the bonds ofthe
blood as red cells, platelets, and various types of white cells. helical structure of the elongated DNA molecules are broken,
The earliest cells of each cell line have similar morphologic and the chromatin strands widen and become more coarse
characteristics and cannot be differentiated by appearance and clumped. In the terminal degenerative and senile stages,
alone. They are given specific names such as ‘‘myeloblast,”’ the nucleus is small, round, dark, and structureless (Plate 1C).
“‘lymphoblast,”’ or ‘‘rubriblast’’ depending on the tissue in One of the signs of immaturity in blood cells is the presence
which they are found, the cells with which they are associated, of nucleoli in the nucleus. These small islands of cytoplasmic
and the definitive cell that they are destined to produce. As material, manufactured within the nucleus, are signs of meta-
the embryonic cells change from their primitive forms to bolic activity and growth. Nucleoli are best seen in very-thin
mature cell types, they undergo changes in nuclear and cyto- smears and may be indistinct and obscured in thick or darkly
plasmic characteristics common to all cells. These changes stained smears. Nucleoli vary in number, shape, and size, but
are detailed in Plate 1. usually there are one to four nucleoli, round or oval in shape,
with diameters in the 2 to 4,um range. They have a fairly homo-
geneous structure and a color similar to that of the cytoplasm.
Maturation Sequence. Immature cells as a class are In methylene blue and eosin stains, the color is predominantly
large and become progressively smaller as they mature (Plate blue. Nucleoli are not bounded by membranes, but the
1A). The nuclei of young cells of the maturation sequence are expanding intranuclear masses tend to compress the
large and relatively large in relation to the cytoplasm. As the surrounding chromatin strands to give the appearance of a
cells age, the absolute and relative size of the nucleus dark boundary (Plate 1D).
decreases (Plate 1B). In cells of the erythrocytic series, the The combined changes in size and color of the cytoplasm
small and degenerated nuclei in the older cells are extruded. and the size, color, and structure of the nucleus are visualized
The cytoplasm of a primitive cell is predominantly blue and in Plate 1D.
contains large amounts of ribonucleic acid (RNA), which has The cytoplasmic shape of cells is influenced by the
an affinity for the basic or blue dye (methylene blue). As the mechanical trauma to which the cells are subjected, the
cytoplasmic structures and secretory products are manu- pressure of surrounding cells, and their ameboid activity.
factured, the color of the cytoplasm becomes more red and Primitive cells tend to be fixed by their cytoplasmic extensions
less blue (Plate 1A). The nuclear chromatin strands of in the ground substance. When torn away from their attach-
immature cells contain deoxyribonucleic acid (DNA), which ments, as in the process of bone marrow aspiration, the
has an affinity for the acidophilic (eosinophilic) red dye. As margins are disrupted, and the edges have a frayed and
the nucleus ages, it stains more intensely, and the color jagged appearance. Mature and free cells in the circulating
changes from purplish-red to dark blue (Plate 1B). blood usually have smooth margins. Cells of the mono-
The most reliable criterion of the age of a given cell and cytic-macrophage system are slowly motile cells that tend to
its position in the maturation sequence is the structure ofthe adhere to glass and plastic surfaces. They continue to spread
nuclear chromatin. In the most-primitive cells, the nuclear out during the drying process. These cells often reveal blunt
chromatin strands are distinctly visible. No part of the cytoplasmic extensions (pseudopods) seldom seen in other
chromatin is darker or more compact than other portions. In cells. Granulocytes and lymphocytes are actively motile cells
some cells, the pattern is linear, whereas in others, the that do not stick readily to the surfaces of slides. These cells
superimposed, tortuous and twisted chromatin threads tend to round up and to become spherical when exposed to
appear as red granules or short rods. If injured in the process the air and as they slowly dry in the thicker portions of smears.

Table 1—Blood Cells

HEMATOPOIETIC TISSUES
CIRCULATING BLOOD
E. Myelocyte. Eosinophil
Myeloblast Promyelocyte N. Myelocyte N. Metamyelocyte__ Neutrophil Neutrophil
Band Segmented
B. Myelocyte Basophil
8 Monoblast________ Promonocyte Monocyte

E Megakaryoblast___ Promegakaryocyte___Megakaryocyte Metamegakaryocyte Thrombocyte

@ Rubriblast_________ Prorubricyte Rubricyte__ Metarubricyte “Bescon Erythrocyte

Erythrocyte

Lymphoblast____ Prolymphocyte Lymphocyte

Plasmoblast____ Proplasmocyte Plasmocyte
 Tissue cells and early cells which move slowly have round, for example, in the nucleated red cells of pernicious anemia
oval, or slightly indented nuclei. Actively motile and mature which may have advanced hemoglobin synthesis and
cells, such as monocytes and granulocytes, have indented, immature nuclear characteristics, or in the cells of iron-
kidney-shaped, lobulated, or segmented nuclei. The nuclei deficiency anemia, in which the hemoglobin is inadequately
of mature lymphocytes are usually round, but they may be formed in cells with pyknotic nuclei.
slightly indented. The nuclei of red cells and plasma cells in
all stages of maturation are round. Reproductive sequence. Inaddition to the changes in
Immature cells that are metabolically active reveal in their cell morphology that are manifestations ofdifferentiation and
cytoplasm a relatively light zone adjacent to the nucleus. This maturation, there are morphologic changes that are mani-
area, known as the Golgi area, contains a smooth endoplasmic festations of reproduction and multiplication. A few primitive
reticulum and centrioles. In this juxtanuclear area, colorless cells in hematopoietic tissues remain undifferentiated and
(achromatic) mitochondria tend to aggregate. The light zone undergo mitotic division that likewise produces undiffer-
near the nucleus is best exemplified in plasmocytes but is entiated cells. Other cells, after the first mitosis, differentiate
visible in immature blood cells of all types. to a degree before they divide again. When these slightly
Granules are not present in stem cells. In the series ofcells more-mature cells undergo mitosis, the daughter cells main-
that characteristically develop granules, the primary granules tain the cytoplasmic characteristics of the parent cells from
are dark and predominantly blue. The specific and secondary which they derive. The majority ofcells enter the mitotic cycle
granules that later develop in the more-mature cells stain less in the intermediate stages of maturation, as for example, in
intensely and are more red and less blue, as exemplified by the promyelocyte or myelocyte stages of the granulocytes or
eosinophils and neutrophils (Plate 3). Manufactured products the prorubricyte or rubricyte stages of the nucleated red cells.
within cells, such as globulin in plasmocytes or hemoglobin After one or several mitotic cycles, the nucleus degenerates
in red cells, are indicative of maturation. and loses its ability to divide.
Phagocytosis of particulate matter is a manifestation of After the mitotic division of the nucleus, the cleavage of
functional activity characteristic of differentiated cells, but the cytoplasm, and the formation of two cells from the parent
the absence of phagocytosis ina given cell at a given time has cell, the nuclear membrane re-forms around the chromo-
no value in determining the maturity of a cell. somes. The cell and its nucleus progressively enlarge. Nucleoli
The cytoplasmic, granular, and nuclear characteristics are appear in the nucleus. During the last few hours ofthe division
usually well-synchronized in normal cells, but in pathological cycle, the nuclear membrane and the nucleoli disappear, and
conditions, the maturation sequences of the various cell the chromatin condenses into dark, compact masses. Each
structures may be out of step with each other. This is the case, chromatin thread divides, spindles extend outward from the

MATURATION

SIZE
decreases
as cell matures
DIVISION

increases
during mitotic cycle

Fig 1—Cell size.

centrosomes, and the chromosomes migrate to the opposite very-irregular shapes and blunt and frayed cytoplasmic pro-
poles. Lines of cleavage appear in the cytoplasm, and two new trusions caused by the violence of cytoplasmic movement
cells are formed. At the time of mitosis, the cytoplasm, like during the act of tearing apart and separating.
the nucleus, is in a state of unrest and assumes a granular or The nuclei of cells during interphase are round. During
bubbly appearance. prophase and in the later stages of mitosis (metaphase,
The volume of any given nucleated cell that is capable of anaphase, and telophase), the nuclear shape is irregular.
replication at any given time is dependent on the quantity The color of the cytoplasm of undifferentiated and blast
of DNA in the nucleus and the quantity of RNA and con- cells participating in the division cycle is blue, but in the more
stituents in the cytoplasm. Each cell, in preparation for differentiated cells, such as hemoglobin-containing nucleated
mitosis, approximately doubles its component of genetic red cells or eosinophils undergoing mitosis, the color of the
material and cytoplasmic organelles before that cell divides. cytoplasm and the structures within the cytoplasm are
During the early growth (G,) phase, the cell is appreciably dependent on the stage of development of the individual cell
smaller than that same cell will be a few hours later. During at the time it entered the reproductive cycle. Whether cells
DNA synthesis (S,) and the later growth (G,) interval, there become more differentiated while they are in the premitotic
is a progressive increase in volume. Frequency-distribution phase is a moot point.
curves of cell diameters in smears of normal, as well as The nuclei of cells may undergo one or more mitotic divi-
pathologic, cells reveal bell-shaped curves. Between the sions without the corresponding division of the cytoplasm,
largest and smallest cells, there are intermediate diameters. producing giant cells with multiple nuclei as exemplified by
Cells that have adequate nutrition and long periods of growth megakaryocytes and by double nuclei in plasmocytes and in
between divisions are larger than are cells with inadequate nucleated red cells. In other cells, the chromosomes may
nutrition, inability to utilize nutrient factors, or shortened replicate without disruption of the nuclear membrane and
mitotic cycles. without division of the nucleus (endomitosis). Other abnor-
Mitotic figures are not demonstrable in smears of periph- malities of nuclear division include: nuclei with too few or too
eral blood of individuals who are in good health. Mitotic many chromosomes; multiple nuclei within a single cell which
figures in bone marrow smears of normal individuals are differ in size, color, and structure; uneven number ofnuclei;
difficult to find. The presence of more than one cell in mitosis and clefts or cleavage lines.
per 1,000 nucleated marrow cells is an indication of abnormal
proliferative activity.
The cytoplasmic shape of cells throughout interphase is Nomenclature. Nucleated cells which are morpholog-
variable. Cells observed during the time of mitosis often have ically undifferentiated (anaplastic) and that cannot, by associ-

Fig 2—Mitotic cycle.

ation with other cells, be identified as blast cells of any given and megakaryocytic series—are given the prefix ‘‘meta’’ for
cell line are tallied and reported as ‘‘stem cells’? (Table 1). the fourth cell (Table 4).
Each clone of definitive cells is given a family name. The The most-frequently employed synonyms for nucleated red
suffix “blast” is reserved for the least-differentiated cells of cells in their various maturation stages are given in Table 5.
each specific cell line. The suffix ‘cyte’? is employed for all The terms ‘reticulum cell,’’ ‘‘reticuloendothelial cell,”’
of the more-mature cells. The prefix ‘Spro”’ is used for the and ‘‘histiocyte’’ are purposely avoided because there is lack
second cell in the maturation sequence, Cells characterized of agreement concerning the morphologic characteristics of
by four maturation stages—such as myelocytic, rubricytic, blood cells designated by these names.

Table 2—Bone Marrow Cells: Table 3—Peripheral Blood Cells:

| Normal Adult Values Normal Adult Values|
Stem cell 0-0.01% Percent Per mms
Myeloblast
aie feel 7m: ae
N. Segmented ie
50-70 gee
2,500-7,000
Wotan a Eosinophil 1-3 50-300
velocyte 2-10 f
N, Metamyelocyte 5-15 Barcel ee Mees
NN. Band 1040 Lymphocyte 20-40 1,000-4,000

N. Segmented 10-30 Money ue J pel :

Eosinophil 0-3
Basophil 0-1

Lymphocyte §-15
Plasmocyte 0-1
Monocyte 0-2
Other cells 0-1

Megakaryocyte 0.1-0.5
|

| Rubriblast 0-1
| Prorubricyte 1-4
Rubricyte 10-20
| Metarubricyte 5-10

| WBC:Nucleated RBC Ratio 4:1

Table 4—Nomenclature _# a
ERYTHROCYTIC
; MYELOCYTIC MONOCYTIC MEGAKARYOCYTIC | (RUBRICYTIC) | LYMPHOCYTIC | PLASMOCYTIC
PREFIX SUFFIX SERIES SERIES SERIES SERIES SERIES SERIES

blast myeloblast monoblast megakaryoblast rubriblast lymphoblast plasmoblast

pro cyte promyelocyte promonocyte promegakaryocyte prorubricyte prolymphocyte proplasmocyte
cyte myelocyte monocyte megakaryocyte rubricyte lymphocyte plasmocyte
meta cyte metamyelocyte metamegakaryocyte | metarubricyte
 FN
can
‘i

PLATE 2—CELL TYPES FOUND IN SMEARS OF PERIPHERAL BLOOD FROM NORMAL INDIVIDUALS

Erythrocytes F Monocyte with gray-blue cytoplasm, coarse

Large lymphocyte with purplish-red (azurophilic) granules linear chromatin, and blunt pseudopods
and deeply indented by adjacent erythrocytes G Thrombocytes
Neutrophilic segmented H Lymphocyte
Eosinophil | Neutrophilic band
> Neutrophilic segmented
WwW
=
iieor@. : J Basophil

The arrangement is arbitrary, and the number of leukocytes in relation to erythrocytes and
thrombocytes is greater than would occur in an actual microscopic field.
LEUKOCYTES, ERYTHROCYTES, THROMBOCYTES
Neutrophilic Leukocytes

C7 RANULAR leukocytes (granulocytes) develop in the bone peripheral blood but are often found in conditions in which
marrow from undifferentiated stem cells (Fig 20) and from there is myelocytic hyperplasia.
precursor cells called myeloblasts. Maturation of the myelo-
cytic series of cells is characterized by the development of dark Neutrophilic band (N. nonsegmented, N. nonfilamented,
and blue-staining primary granules which are later replaced N. staffor stab). As the neutrophilic metamyelocyte matures,
by secondary granules that differ in their affinity for various the nuclear indentation becomes more marked until a stage
dyes. Cells that have granules with an affinity for blue or basic is reached in which the indentation is greater than half the
dye are called basophils; those that are stained reddish-orange width of the hypothetical round nucleus. The opposite edges
with the acid dye, eosin, are called eosinophils; and the cells of the nucleus become approximately parallel for an appre-
with granules that do not stain intensely with either dye are ciable distance giving a horseshoe appearance (Fig. 3). Neu-
called neutrophils. As the cells acquire mobility, the nuclei trophilic bands are slightly smaller than metamyelocytes. The
of the neutrophilic, eosinophilic, and basophilic systems of nucleus shows degenerative changes, and there is usually a
granular cells undergo progressive changes from round to dark pyknotic mass at each pole where the lobe is destined
multilobular forms designated respectively as myelocytes, to be. The granules of band neutrophils are small and evenly
metamyelocytes, band, and segmented forms (Plate 3). distributed and stain various shades of pink and blue (Plate 3).
Neutrophilic band forms constitute from 1 % to 5% of the
Myeloblast. This cell varies in diameter from 15 to 20 pm. leukocytes in the peripheral blood of healthy individuals. An
There is a moderate amount of bluish nongranular cytoplasm, increase in nonfilamented forms and other immature
which stains unevenly and is lighter next to the nucleus than neutrophils is known as a ‘“‘shift to the left’? and is an
at the periphery. Cytoplasmic tags are often demonstrable. indication of an abnormal response.
The nucleus is round and stains predominantly red. The
interlaced chromatin strands are delicate, well defined, and Neutrophilic segmented (N. filamented, N. poly-
evenly stained. Two or more nucleoli are usually demonstrable morphonuclear, PMN, polymorphonuclear neutrophilic
(Plate 3). granulocyte). This cell differs from the neutrophilic band in
that the nucleus is now separated into definite lobes with a
Promyelocyte (Progranulocyte). A cell ceases to be a
very-narrow filament or strand connecting the lobes. The
myeloblast and becomes a promyelocyte when it develops
mature neutrophil is approximately twice the size of an ery-
distinct granules (Plate 3). The earliest granules are dark-blue
throcyte. The cytoplasm in an ideal stain is light pink and the
or reddish-blue. Most of the granules are round, but some may
small, numerous, and evenly distributed granules have a light-
be elongated, curved, and irregular in shape. Granules may
pink to bluish-purple color (Plate 2, Plate 3).
be visible above and below the relatively lightly stained and
Segmented neutrophils in the peripheral blood of older
purple-red nucleus.
The nucleus is round or oval and relatively large in relation children and adults range from 50% to 70% with an average
of 60%. On the average, 5% of the neutrophils have one lobe,
to the cytoplasm (Plate 3). The chromatin structure is slightly
35% two lobes,41 % three lobes, 17% four lobes, and 2% five
coarser, and the strands of chromatin are bluer and not as
or more lobes. In pernicious anemia and related B,, and folic-
red as in the myeloblast. Nucleoli may be visible but are
usually indistinct. The cytoplasm is blue with a relatively light acid deficiencies, there is an increase in hyperlobulated (six
or more lobes) neutrophils (Plate 27, Plate 31).
zone adjacent to the nucleus. The cytoplasmic margins are
The transition between the various stages of granulocytes
smooth, and the cell does not indent nor is it compressed by
neighboring cells. Since some early granulocytes are still is gradual. Many cells are borderline and difficult to
distinguish from each other. The major difficulty is that of
capable of reproduction, the size may be quite variable,
differentiating between band and segmenting forms and
depending on the stage of a given cell in the mitotic cycle.
A promyelocyte becomes a myelocyte when the granules deciding whether the margins of the isthmus between two
differentiate to such a degree that one can identify the lobes are parallel and whether the connecting link is wide
granules as basophilic, eosinophilic, or neutrophilic. enough to be interpreted as a ‘“‘band”’ or narrow enough to
be identified as a ‘‘filament.’’ A ‘‘band”’ is defined as a
Neutrophilic myelocyte. The first sign of neutrophilic connecting strip or isthmus with parallel sides and wide
differentiation or ‘‘dawn of neutrophilia’ is the development enough to reveal two distinct margins with nuclear chromatin
of asmall, relatively light island ofill-defined reddish granules material visible between the margins. A ‘‘filament”’ is defined
adjacent to the nucleus (Plate 3, Plate 6). In older myelocytes, as a threadlike connection between two lobes so narrow that
the dark granules become less prominent, and the neutro- there is no visible chromatin between the two sides. In its most
philic granules predominate. Neutrophilic myelocytes are characteristic form, the shape of a ‘‘band”’ (nonsegmented,
usually smaller than progranulocytes and have relatively nonfilamented) nucleus is that of a bent stick, a horseshoe,
larger amounts of cytoplasm. The nuclei are round, oval, or or a curved link of sausage. Lobes of nuclei often touch or
flattened on one side. The chromatin strands are unevenly are superimposed so it is impossible to see connecting links.
stained and thickened. Nucleoli are indistinct. If the margin of a given lobe can be traced as a definite and
continuing line from one side across the isthmus to the other
Neutrophilic metamyelocyte (Juvenile). A neutro- side, it is assumed that a filament is present even though it
philic metamyelocyte has a slightly indented nucleus and is not visible (Fig 4). In differentiating between segmented
small, pinkish-blue granules. As a class, these cells are slightly (filamented) and band (nonsegmented, nonfilamented) nuclei,
smaller than myelocytes and have relatively smaller nuclei do not restrict evaluation to any single morphological charac-
and less-well-defined chromatin structures (Plate 3, Plate 6). teristic but combine features including parallel sides and
Neutrophilic metamyelocytes are rarely seen in normal width of the connecting link, visibility of chromatin at the
 PLATE 3—MYELOCYTIC (GRANULOCYTIC) SYSTEM

A Myeloblast
B Promyelocyte (progranulocyte)

C Basophilic myelocyte G Neutrophitic myelocyte K Eosinophilic myelocyte

D Basophilic metamyelocyte H Neutrophilic metamyelocyte L Eosinophilic metamyelocyte
E Basophilic band | Neutrophilic band M Eosinophilic band
F Basophilic segmented J Neutrophilic segmented N Eosinophilic segmented
 i)
i)
'
'

MYELOCYTE METAMYELOCYTE BAND SEGMENTED

Fig 3— Terminology based on indentation of nuclei.

NONSEGMENTED

©©OOD®©
ZOO @
SEGMENTED

Fig 4—Neutrophil nonsegmented and segmented cells.

narrowest portion, and superimposition of lobes. In case of Occasionally, asynchronous Pelger-like (pseudo-Pelger)
doubt, the rule is to place the questionable cell in the more- hypolobulated cells may be demonstrable in small numbers
mature or segmented category most likely to be correct. in smears of blood and bone marrow of patients with
myelocytic leukemia, severe infections, or other diseases.
Morphological Abnormalities. Numerous structural Prominent purplish and blue-black granules, designated
abnormalities that are visible by light microscopy in the as “‘toxic granules,”’ often are demonstrable in the cytoplasm
cytoplasm and nuclei of neutrophils are useful in the diagnosis of neutrophils in association with severe infections and other
and differential diagnosis of various diseases and conditions. toxic states. Toxic granules vary in size, shape, and distribu-
Hyperlobulated metamyelocytes and nonsegmented (band) tion as well as in color (Plate 31). Morphologically, toxic
neutrophils and segmented cells with five or more lobes are granules resemble the primary granules of promyelocytes and
characteristic findings in smears of blood of patients with early neutrophilic myelocytes. Toxic granules are manifes-
pernicious anemia and related B,,-folic acid deficiencies tations of asynchronism between the maturation of nuclei and
(Fig 5, Plate 31, Plate 27). As a rule, hyperlobulated and lysosomes.
hypersegmented neutrophils are larger than normal cells. Dohle bodies (Amato bodies) are inconspicuous pale sky-
Hypersegmentation of giant neutrophils, as well as hyper- blue cytoplasmic inclusions: They most frequently are demon-
segmentation of cells of normal size, may be inherited strable in band and segmented neutrophils. Based on electron
characteristics. microscopic evidence, the cerulean-blue areas are residual
Hypolobulation ofthe nuclei of neutrophils and eosinophils aggregates of rough endoplasmic reticulum. Dohle bodies
is a characteristic feature of the inherited and benign con- vary in number, distribution, and size. Some have round or
dition known as *‘Pelger-Huét anomaly.”’ In the homozygous oval shapes, while others appear as blue splotches with
form, the nuclei of most of the neutrophils are round. In the nebulous extensions. Focal areas of basophilia often are
heterozygous condition, the nuclei of the majority of demonstrable in leukocytes that also contain “‘toxic
neutrophilic leukocytes have two round lobes which are granules.’’ Déhle bodies may be demonstrable in numerous
closely approximated and connected by short filaments (pince- infectious diseases, as well as burns, toxemia of pregnancy,
nez form). Other nuclei are round or have dumbbell or kidney diseases due to exposure to cytotoxic chemicals, plant and
shapes (Plate 33). The nuclear chromatin and granules of animal poisons, and the hereditary May-Hegglin anomaly
hypolobulated neutrophils have normal features. (Plate 36).

Fig 5—Hyperlobulated macroneutrophils, pernicious anemia.

 Eosinophils

The cytoplasm of neutrophils as well as other cells of Bikes are characterized by relatively large, spher-
patients with Alder’s (Alder-Reilly) anomaly contains multiple ical granules that have a particular affinity for the acid eosin
dark-blue round or oval granules (Plate 34). stain. The earliest recognizable eosinophils have a few dark
The lysosomes in the cytoplasm of granulocytes in patients and bluish primary granules intermingled with the secondary
with Chédiak-Higashi syndrome are grossly enlarged and vary and specific red granules. As the eosinophils pass through
in color from blue-black to light red and pink (Plate 35). their various developmental stages, the bluish granules, char-
Auer bodies (Auer rods) are elongated narrow purplish-red acteristic of the progranulocyte and the early myelocyte
structures of uncertain nature that are demonstrable in the stages, disappear (Plate 3). Because the percentage of eosino-
cytoplasm of myeloblasts and monoblasts and, in rare phils is usually low in bone marrow and peripheral blood
instances, in more-mature granulocytic cells. The number in smears, no useful clinical purpose is served by routinely
a given cell varies, but, as arule, there is only one (Plate 40). separating the eosinophils into their various myelocyte,
They reveal positive reactions when peroxidase, Sudan black, metamyelocyte, band, and segmented categories. On the
and acid phosphatase stains are used. Auer rods are not other hand, in situations in which the eosinophils are greatly
demonstrable in cells of the lymphocytic, plasmocytic, increased, an analysis of the incidence of the various stages
erythrocytic, and megakaryocytic systems. is indicated.
Spherical chromophobic areas (vacuoles) in the cytoplasm The eosinophils as seen in normal peripheral blood smears
or in nuclei are manifestations of degenerative changes are about the size of neutrophils, and usually have band or
(Plate 31). two-lobed nuclei. The granules are spherical and uniform in
Lupus erythematosus is an auto-immune disease character- size. They usually are evenly distributed in the cell and fill
ized by the presence of antinuclear antibodies. When it. Rarely do they overlie the nucleus (Plate 2, Plate 3). In good
aspirates of bone marrow or blood are allowed to stand outside stains, the granules take a bright reddish-orange stain with
of the body before the preparation and staining of smears, brownish tints. On focusing up and down, one can bring out
some of the nuclei in some of the leukocytes undergo lytic highlights on individual granules or reveal them as little
changes (pre-LE cells) (Plate 32). Motile neutrophils are circles. Often this spherical shape permits identification of
attracted to the cells that have undergone degenerative the cell when the stain is unsatisfactory. (Eosinophils can be
changes. These neutrophils form clusters or rosettes around identified readily in moist preparations without the use of
the lysed cells (Plate 32). Viable neutrophils phagocytize stains, because the granules are distinct, round, relatively
nuclear material, producing within the digestive vacuoles of large, and of a brownish color.) Often it is difficult to dis-
their cytoplasm round or oval inclusions which have a fairly tinguish eosinophils from neutrophils when the granules of
homogeneous structure and stain purplish-red (Plate 32). Neu- the neutrophil are prominent and stain darkly. In case of
trophils that contain inclusions that are reddish-purple and doubt, the questionable cell should be called a neutrophil.
structureless are called LE cells. Neutrophils that have By moving to the thin part of the field (with brighter illumi-
engulfed lysed nuclear masses may themselves undergo nation)—and paying attention to the size, uniformity, and
degenerative changes producing post-LE cells (Plate 32). shape of the granules rather than to the color alone—one can
Morphological changes ofthe types described above are not often make distinctions that otherwise would be guesswork.
specific for lupus erythematosus. The final diagnosis should Eosinophils, like neutrophils and basophils, are derived
be based on combined clinical manifestations and other lab- from progenitor myeloblasts and myelocytes (Plate 3, Plate
oratory tests. 54).
Structureless red-staining cytoplasmic inclusions of the Eosinophils constitute from 1% to 3% of leukocytes in
type demonstrable in stained smears of bone marrow and smears of peripheral blood of normal individuals. There is
body fluids in patients with lupus erythematosus are to be a relative and absolute eosinophilia in association with the
differentiated from linear and/or lumpy nuclei that stain dark invasion, migration, and encystment of animal (metazoa)
blue and that are contained in the cytoplasm of monocytes parasites. Other diseases and conditions characterized by an
(Plate 31). Monocytes that have ingested nonlysed nuclei are increase in eosinophils include bronchial asthma, hay fever,
designated as ‘Tart cells,’’ so named because they resemble Léffler’s syndrome, extensive skin lesions, recovery from bac-
the cells that were observed and reported in smears of bone terial and other infections, chronic myelocytic and eosin-
marrow of Mr. Tart who was a patient at the Mayo Clinic. ophilic leukemia, and some cases of neoplastic malignancy.
Eosinopenia occurs in conditions of stress, such as shock,
severe burns, and severe infections. The absence of
eosinophils in blood in surgical conditions is an unfavorable
omen and the presence of—or an increase in—eosinophils
is a favorable sign. Eosinophils are decreased by the admin-
istration of adrenal corticosteroids.
Eosinophilic leukocytes are motile cells that are infre-
quently phagocytic. They leave the blood and enter tissue
spaces at the sites of antigen-antibody contacts. It is thought
that the histamine liberated from basophils during the initial
stage of an allergic reaction serves as a chemotactic factor.
Eosinophils aid in the restraint and control ofinflammatory
reactions. They also have cytotoxic properties against invad-
ing animal parasites.

10
Basophilic Leukocytes Granules of the type present in basophilic leukocytes have
(Basophils, Basophilic Granulocytes) a love or an affinity for basic dyes. When stained by a single
blue dye such as toluidine blue; azure A, B, or C; or other blue
and basic dyes, the granules, instead of revealing the blue
color of the dye that was used, are red (metachromasia). The
Wright stain contains two dyes: the red dye, eosin, and the
B.... BASOPHILS which are derived from myeloblasts and blue dye, methylene blue. The granules of basophilic
progranulocytes have round, indented, band, or segmented leukocytes, when stained by the Wright method, reveal vary-
nuclei (Plate 2, Plate 3, Plate 54, Fig 6). Based on the shape ing shades of red and blue. The predominant color is blue.
of their nuclei, they may be classified as basophilic myelo- The granules of basophilic leukocytes yield negative or very
cytes, metamyelocytes, and band and segmented forms, but weak peroxidase, Sudan black, and alkaline phosphatase
the cells are so few in peripheral blood and bone marrow reactions. Some basophils react positively when periodic acid
smears that there is no clinical advantage in placing the cells Schiff (PAS) stain is used.
in separate categories. Basophils differ from neutrophils and monocytes in that
Blood basophils in all stages of their maturation are smaller they are not phagocytic. The granules in basophils are
than promyelocytes, and their size is approximately the same membrane-bound sacks containing secretory products
as that of neutrophils in the same or closely adjacent micro- including heparin, histamine, and other chemicals. They are
scopic fields (Fig 6). The margins are smooth, and the shape not lysosomes that contain digestive enzymes. When properly
is round or oval. Nuclei, in contrast to the darkly stained stimulated, the granules present in basophilic leukocytes eject
granules, are inconspicuous. The color of the nuclei is the chemicals contained in their storage areas (exocytosis).
purple-red. The number of leukocytes with basophilic granules in
Basophilic granules vary in size from 0.2 to 1.0 um. Most smears of peripheral blood or bone marrow of normal
of the granules are round. They are numerous and unevenly individuals is less than one per 100 nucleated cells.
distributed. The color of the granules varies from deep The most striking relative and absolute increase in baso-
purplish-blue to dark purple-red. Due to intense staining, the philic leukocytes in the peripheral blood as well as in the bone
granules stand out in sharp contrast to the light purplish color marrow occurs as a manifestation of basophilic (mast cell)
of the cytoplasm. The darkly stained granules are visible leukemia. There is a relative and absolute, but less-marked,
above and below the lightly stained nuclei. increase in the number of basophils in chronic myelocytic
The basophilic granules are water soluble. In smears, leukemia and in myeloblastic crisis.
imprints, or sections of bone marrow that are exposed to Since basophils in blood and bone marrow smears are
moisture before being fixed or that are poorly fixed during present in such small numbers, the failure to find these cells
the staining process, the granules disappear, leaving small, during a differential count of several hundred cells is without
round, and colorless cytoplasmic areas. clinical significance.

Fig 6—A Segmented neutrophil, basophil

B Promyelocyte
C Nucleated red cell, basophil

11
 Monocytes is fine and distinct, nucleoli are demonstrable, and there are
no granules in the cytoplasm (Plate 41).
(Large Mononuclears)
Monocytes vs Neutrophils vs Large Lympho-
cytes. Monocytes are the cells of the peripheral blood most
difficult to identify and to differentiate from other cells (Plate
6). They are frequently mistaken for neutrophils, for they may
have prominent granules and lobulated nuclei. The monocyte
NM ONOCYTES are phagocytic leukocytes of the blood often is mistaken for a large lymphocyte, because its cyto-
which, together with tissue macrophages and neutrophilic leu- plasm is blue, or because the granules may be indistinct, the
kocytes, play a major role as a first line of defense against nucleus round or only slightly indented, the linear chromatin
pathogenic organisms and nonself or foreign cells. pattern ill defined, and the distinctive blunt pseudopods and
In smears of peripheral blood from healthy individuals, digestive vacuoles missing.
monocytes usually range from 1 % to 6%. In smears of bone The three most characteristic features of the monocyte and
marrow from persons in good health, monocytes usually con- the most helpful in diagnosis are the dull gray-blue color of
stitute less than 2%. the cytoplasm, the blunt pseudopods, and the brainlike con-
Monocytes as a class are slightly larger than neutrophils, volutions of the nucleus.
and their diameters are three to four times those oferythro- The color of the cytoplasm must not be compared with a
cytes in the same microscopic fields (Plate 2). Generally, there textbook picture or hypothetical ideal cells, but with known
is a large amount of cytoplasm in relation to the nucleus. neutrophils in the same or adjacent fields. The cytoplasm of
The shape of monocytes is variable (Plate 4). Many are aneutrophil is relatively light and reddish in comparison with
round or oval. Others reveal blunt pseudopods which are the cytoplasm of the monocyte which is relatively dark, more
manifestations of their slow motility. These ameboid and bluish, and more opaque. Neutrophils practically never have
aggressive cells continue to move while the blood film is blunt pseudopods.
drying and become fixed before there is time to retract their To distinguish monocytes from large lymphocytes, the
cytoplasmic extensions. The pseudopods vary in size and in nuclear structure, the character of the cytoplasm, and the
number. The outer portion of the outstretched cytoplasm shape of the cells are most useful. The nucleus of a lympho-
(ectoplasm) often has a transparent or hyaline appearance as cyte tends to be clumped, rather than linear (Plate 6). There
contrasted with the granular inner cytoplasm (endoplasm). is a greater tendency for the nuclear chromatin to be
The cytoplasm in the Wright-stained smear is dull gray- condensed at the periphery in the lymphocyte. Brainlike
blue as contrasted with the color of the cytoplasm of neu- convolutions are not present in the lymphocyte. Monocytes
trophils in adjacent fields which is less-intensely stained and and large lymphocytes may have distinct bluish-red granules
is pink. (lysosomes). In addition, the cytoplasm of the monocyte has
The granules of monocytes are usually fine, lightly stained, a finely granular or ground-glass appearance, whereas the
numerous, and evenly distributed, giving to the cells a ground- cytoplasm of the lymphocyte has a background that is
glass appearance. In other cells, there may be, in addition to nongranular.
the small granules, varying numbers of prominent granules. Monocytes tend to indent and to compress adjacent cells
Vacuoles are often prominent in the cytoplasm. Phagocytized rather than to be indented by them. Large lymphocytes, on
erythrocytes, leukocytes, nuclei, cell fragments, pigment, bac- the other hand, are often deeply indented by neighboring cells
teria, and fungi may be demonstrable in digestive vacuoles. (Plate 2, Plate 5).
The nucleus of the monocyte is usually round or kidney-
shaped, but may be deeply indented or have two or more lobes Morphological Abnormalities. Extremely large
separated by narrow filaments. One of the most distinctive monocytes (macrophages) in smears ofperipheral blood may
and diagnostic features of the monocyte is the presence of be demonstrable in patients with subacute bacterial endo-
brainlike convolutions. Another feature of the nucleus of value carditis and other chronic infectious states. These large cells,
in identification is the tendency of the nuclear chromatin to some of which may contain phagocytized particulate matter,
be loose with light spaces in between the chromatin strands, are most likely to be found at the feather edge of smears made
giving a coarse, linear pattern in contrast to the lymphocyte from blood of the ear rather than from other sites.
with its clumped chromatin. In its cytoplasm, a monocyte may contain intact and
Monocytes are derived from stem cells in the bone marrow. hemoglobin-containing red cells, red-cell fragments, and
As these cells grow, they are transformed into macrophages hemosiderin granules, as well as phagocytized leukocytes and
too large to pass readily through capillaries. Extremely large leukocyte fragments.
mononuclear phagocytes are seldom seen in blood smears but Alveolar monophagocytes ingest and degrade pathogenic
are demonstrable in body fluids other than blood. Some of organisms. They also phagocytize particles containing in-
the macrophages become anchored in connective tissues spired air and serve as a means oftransportation of pollutants
where they are entrapped by reticular and collagen fibers. by ciliated epithelial cells lining the respiratory tract.
The smaller monocytes, the larger wandering macrophages, Phagocytic cells of varying size and mobility remove from
and the semifixed or fixed phagocytes are thought to be the circulating blood injured and dead cells, cell fragments,
capable of reversible transformation from one to the other. microorganisms, and insoluble particles. Motile monophag-
ocytes escaping between epithelial lining cells of the upper
Promonocytes and Monoblasts are not identifiable and lower respiratory tracts and the gastrointestinal and
as such in bone marrow or peripheral blood smears except genitourinary organs perform a scavenger function, clearing
in conditions in which there is marked proliferation of cells the body of insoluble and unneeded debris.
of the monocytic type as in monocytic leukemia. The identi- An important function of micromonocytes as well as macro-
fication of early mononuclear cells is based on the indented monocytes (macrophages) is to ingest and kill pathogenic
and folded nuclei and the association with more mature organisms and to ingest and degrade noxious external agents.
monocytes having blunt pseudopods, vacuoles, and phago- Monophagocytes also play a role in phagocytizing old and
cytic particles in the cytoplasm. The cells in monocytic degenerated cells and cell fragments, malignant cells, and
leukemia are called monoblasts when the nuclear chromatin cells that spontaneously undergo mutations in the body.

12
 PLATE 4—MONOCYTES
Monocyte with “ground-glass’ appearance, E Monocyte with gray-blue color, band type of
evenly distributed fine granules, occasional nucleus, linear chromatin, blunt pseudopods,
azurophilic granules, and vacuoles in cytoplasm and granules
Monocyte with opaque cytoplasm and Monocyte with gray-blue color, irregular shape,
granules and with lobulation of nucleus and multilobulated nucleus
and linear chromatin G Monocyte with segmented nucleus
Monocyte with prominent granules and H Monocyte with multiple blunt nongranular
deeply indented nucleus pseudopods, nuclear indentations, and folds
Monocyte without nuclear indentations Monocyte with vacuoles and with nongranular
ectoplasm and granular endoplasm

13
 LYMPHOCYTES

MONOCYTES

Fig 7—Cell shapes.

14
Lymphocytes Lymphoblasts and Prolymphocytes. Lymphoblasts,
prolymphocytes, and small lymphocytes have similar morpho-
logic characteristics in that each has a relatively large, round
or slightly indented nucleus and blue cytoplasm. The nuclei
of nonfunctioning cells become progressively smaller as the
cells mature (Plate 7, left column). Differentiation of cells in
ee are the predominant cells in the lymph and a maturation sequence is based principally on differences in
are the second most-frequently-occurring leukocytes of the nuclear structure. In lymphoblasts, the chromatin strands are
blood. During the first few years of life, while children are thin, evenly stained, and reddish-purple. One or several
developing immunity to infectious agents and other foreign nucleoli are demonstrable (Plate 7, Plate 39). In mature
environmental factors, lymphocytes constitute 30% to 70% lymphocytes, the nucleus stains darkly and the chromatin is
of leukocytes in peripheral blood smears and 10% to 30% lumpy. Nucleoli in prolymphocytes are usually less distinct
in bone marrow smears. In older children and adults, lym- than in lymphoblasts, and the chromatin color and structure
phocytes constitute from 20% to 40% of the leukocytes in are intermediate. These differences are subtle. It is often a
peripheral blood smears and 5% to 15% ofthe nucleated cells matter of opinion as to the category in which individual
in bone marrow smears. The total number of lymphocytes in lymphocytic cells should be placed. In case of doubt whether
the blood of individuals in good health varies from 1.5 to 4.0 a given cell is a lymphocyte, a prolymphocyte, or a lympho-
x 1LO°/L. blast, identify it as a lymphocyte.

Small Lymphocytes. The traditional and textbook de- Large Lymphocytes. In addition to small lymphocytes
scriptions of lymphocytes relate to cells in the resting or with pachychromatic nuclei and small amounts of bluish
dormant stages demonstrable in smears of bone marrow, nongranular cytoplasm, there are—in smears of peripheral
blood, or other body fluids of individuals in good health and/or blood of normal individuals—a few large lymphocytes, some
those who are not exposed to antigenic stimuli. These latent of which contain granules. The largest lymphocytes have
cells maintain metabolic activity sufficient for survival, but diameters two to three times those of small lymphocytes in
they are not immunologically functional. Some of the lympho- the same microscopic fields. In addition to the large and small
cytes that appear to be old and degenerate—because their lymphocytes, there are intermediate sizes. The number of
nuclei are darkly stained, the chromatin condensed, and large lymphocytes in the smears of normal peripheral blood
nucleoli invisible—have the capacity, after activation by usually ranges between 5% and 10% of the number of
antigens, of transforming into cells that are immunologically lymphocytes.
functional. Small lymphocytes with round nuclei and blue The diameters of nuclei of large lymphocytes, in relation
nongranular cytoplasm are identified and morphologically to the nuclei of small lymphocytes, are significantly increased.
differentiated from other nucleated cells by the charac- The shape, staining characteristics, and chromatin structure
teristics they lack rather than the anatomical features they are similar to those described above for small lymphocytes.
reveal. Nucleoli, as a rule, are not visible by light microscopy.
The diameters of small lymphocytes are in the 7 to 10 um The margins of large lymphocytes are often indented by
range. The nucleus in relation to the cytoplasm is large. The erythrocytes, producing serrated, scalloped, or holly-leaf
size of the nucleus of small lymphocytes is comparable to the shapes (Plate 5J,K,L). Whether the marginal indentations are
diameters of normal red cells in the same microscopic fields. manifestations of the plasticity and easy compressibility of
Small lymphocytes usually have a narrow rim of cytoplasm. the cytoplasm or are due to the affinity of red cells and
The nuclear chromatin in small lymphocytes is clumped lymphocytes is not known.
and darkly stained. Thin sections of small lymphocytes The light-blue cytoplasm of some lymphocytes on casual
examined by electron microscopy reveal the presence of examination is structureless, but on critical illumination and
nucleoli in some of the cells, depending on the metabolic by using a superior oil-immersion system, there are fine,
activity of any given cell at the time offixation. Nucleoli that bluish interlacing fibrils. Areas between these fine reticular
may be present in older lymphocytes are not visible by light and weblike strands take a relatively light stain (Plate 5, Plate
microscopy because they are obscured by dense chromatin 6, Plate 7).
masses. The fact that nucleoli are present in some small Some large lymphocytes contain a few unevenly distributed
lymphocytes is proof of metabolic activity and the capacity granules. The size of individual granules is approximately the
of these cells for growth and replication. same. The granules are spherical, have a purplish-red color,
Small lymphocytes usually have round shapes and smooth and often have a clear zone or halo around them. The granules
cytoplasmic margins (Plate 5B). Some small lymphocytes in lymphocytes have been designated as “‘azurophilic,”’ but
reveal a few small and pointed cytoplasmic protrusions (Plate this term is misleading because the color is predominantly
5G). One of the shapes seldom seen in nucleated cells other red rather than blue. This is due to the fact that the blue dye
than lymphocytes is the spindle form with oval and centrally stains this type of granule a red color (metachromasia). The
located nuclei and with tapering filaments extending outward granules in lymphocytes differ from those in neutrophilic
at each end (Plate 5F). In some conditions—such as lymph- leukocytes in that they are less numerous, are unevenly
ocytic leukemias-—in which there are numerous lymphocytes, distributed, and are peroxidase- and Sudan black B-negative
there are multiple spindle-shaped lymphocytes with their long rather than positive. Granules in lymphocytes are acid
axes parallel, resembling schools of swimming fish. phosphatase positive.
The color of the cytoplasm is blue. The intensity of the blue The role that large lymphocytes play in immunologic
color in different cells varies from light to dark. The color is reactions and their relationship to small lymphocytes and to
evenly distributed in some cells and is uneven and splotchy lymphoblasts is veiled in mystery. On the basis of the structure
in others. As arule, the intensity ofthe stain is greater at the of nuclei and in the presence of well-defined granules in the
margins than in the central portions. Transmitted light cytoplasm of some of the cells, it is obvious that these cells
deflected by the deeply stained nuclei tends to highlight the are mature variants. It is probable that large lymphocytes,
cytoplasm adjacent to the nucleus, producing a perinuclear in contrast to small lymphocytes, are immunologically
“silver lining”’ or ‘“‘halo”’ effect (Plate 5B, Plate 6F). functional as units in bodily defense. The survival time of

15
 PLATE 5—LYMPHOCYTES

Small mature lymphocyte Large lymphocyte

Lymphocyte of intermediate size Large lymphocyte with purplish-red (azurophilic)
Lymphocyte with indented nucleus granules
Lymphocyte of intermediate size Large lymphocyte with irregular cytoplasmic
Lymphocyte with pointed cytoplasmic
moOOWpyp contours
Projections (frayed cytoplasm); typical nucleus Large lymphocyte with purplish-red (azurophilic)
Spindle-shaped lymphocyte with indented granules and with indentations caused by pressure
nucleus of erythrocytes
Large lymphocyte with indented nucleus and Large lymphocyte with purplish-red (azurophilic)
pointed cytoplasmic projections granules

16
 PLATE 6—COMPARATIVE MORPHOLOGY:
NEUTROPHILIC GRANULOCYTES, MONOCYTES, LYMPHOCYTES

A N. myelocyte with mixture of neutrophilic and F Large lymphocyte with nongranular cytoplasm
dark reddish-purple granules G N. myelocyte
Monocyte with nuclear fold H Typical monocyte with lobulated nucleus,
Large lymphocyte with scalloped shape and gray-blue color, and blunt pseudopods
absence of folds in nucleus | Large lymphocyte with purplish-red (azurophilic)
N. metamyelocyte with light-pink cytoplasm color granules and lumpy nuclear structure
and neutrophilic granules
m Monocyte with gray-blue cytoplasm, prominent
@iw
OP
granules and multilobulated nucleus (brainlike
convolutions), and linear chromatin strands

17
 PLATE 7—LYMPHOCYTIC, MONOCYTIC, AND PLASMOCYTIC SYSTEMS

A Lymphoblast F Proplasmocyte
B Monoblast G Lymphocyte with
C Plasmoblast clumped chromatin
D Prolymphocyte H Monocyte
E Promonocyte | Plasmocyte

18
large lymphocytes is not known. Since these cells have large rule, there are no nucleated red cells. Thrombocytes are
amounts of cytoplasm, it is unlikely that they recirculate, as present in normal numbers. These signs are extremely helpful
do some small lymphocytes from the blood stream, into tissue in diagnosis between benign and malignant conditions. In
spaces of lymph nodes and back again into the blood stream leukemic states, the normal bone marrow cells usually are
via lymphatic channels. replaced by malignant cells. The bone marrow in patients with
There is no useful purpose served by reporting so-called infectious mononucleosis may reveal granulomatous areas in
‘large’ and “‘small’’ lymphocytes because there are no estab- tissue sections, but there is no replacement of marrow cells
lished criteria for separation according to size. However, if by lymphocytes.
there is a striking increase in large lymphocytes, with or Viruses other than the EBV of infectious mononucleosis
without granules, this abnormality should be included in the that are characterized by an increased proliferation of
laboratory report. reactive lymphocytes include the cytomegalovirus and the
etiologic agents of hepatitis, herpes zoster (shingles), viral
Activated and Reactive Lymphocytes. Some small pneumonia, lymphocytic choriomeningitis, mumps, rubeola,
lymphocytes have darkly stained pachychromatic nuclei and rubella, chicken pox, and smallpox. Reactive lymphocytes are
relatively small amounts of bluish nongranular cytoplasm and demonstrable in a host of other diseases and conditions, such
appear to be old by conventional morphological criteria. as auto-immune diseases, reactions to drugs and plant and
However, they prove not to be old when they are stimulated animal poisons, allergic skin diseases, serum sickness, post-
by appropriate antigens and are shown to be capable ofreju- transfusion reactions, organ transplants, and infections due
venation and transformation into cells that grow, proliferate, to protozoa, fungi, spirochetes, and rickettsiae. Reactive
and evolve into cells that are immunologically competent. lymphocytes are demonstrable also during the recovery phase
The size of transformed lymphocytes varies (Plate 38), but of bacterial infections.
usually they are significantly larger than the small lympho- Since malignant cells of various types are foreign to the
cytes from which they are derived. The increase in volume body, itis possible to find reactive lymphocytes in association
in the later phases of preparation for mitosis is due to an with leukemias, lymphomas, and other malignant diseases.
increase in DNA in the nuclei and RNA in the cytoplasm. It is recommended that large lymphocytes with varying
There also is an increase in rough endoplasmic reticulum and degrees of cytoplasmic basophilia and those with immature
in the number and size of mitochondria. In some large nuclear characteristics, abnormal shapes, and unusual cyto-
reactive cells, granules are present. The nuclei of some of the plasmic structures be reported on the laboratory report form
lymphocytes that are responding to activation by antigens as “‘lymphocyte variants.’ This term is preferable to
have leptochromatic (blastlike) nuclei and visible nucleoli. ‘atypical lymphocytes,”’ because the morphologic changes
Smears of peripheral blood and bone marrow of patients that occur in lymphocytes which respond to antigenic stim-
whose lymphocytes are activated by antigens may reveal large ulants are typical of immunologically functional cells,
monocytoid cells (? lymphocyte, ? monocyte) with oval, although they are not typical of cells that are in the resting
indented, or lobulated nuclei; granular cytoplasm; vacuoles; or dormant phase.
and blunt pseudopods (Plate 37). Lymphocytes that respond Eponyms such as ‘‘Tiirk irritation cells’’ and ‘‘Downey I,
to antigenic stimuli constitute a heterogeneous population II, and III’ should not be used. It is difficult enough for
or wide spectrum of morphologic variants (Plate 38). There students to remember descriptive terms without having to
is no single term that can possibly describe all types of reactive remember the names of famous hematologists who years ago
cells any more than one color can adequately describe a first described morphologic variants. The term, “‘pyronin-
rainbow. ophilic cells,”’ is taboo unless the supravital stain, “‘pyronin,”’
The most striking variants, and the greatest number of was actually employed and the cytoplasm revealed an affinity
transformed or reactive lymphocytes, are demonstrable in the for the red dye. “‘Virocyte”’ is an unacceptable term because
smears ofperipheral blood ofpatients with infectious mono- while it is true that reactive cells often are present in asso-
nucleosis, a febrile lymphoproliferative disease which is ciation with viral diseases, the same types ofreactive cells also
usually relatively benign and self limiting. The etiologic agent are present in nonviral diseases and conditions.
is the Epstein-Barr virus (EBV). During the first few days, The pathologist responsible for the anatomical diagnosis
there may be aslight neutropenia, but by the time the patient and the clinician responsible for the clinical diagnosis and
seeks medical care, the total leukocyte count is usually slightly establishment of prognosis and treatment have the freedom
elevated. Small to intermediate lymphocytes usually con- to employ any interpretive changes they may choose, includ-
stitute 60% or more of the leukocytes. The majority of lymph- ing terms that imply assumed trigger factors such as
ocytes have normal nuclear and cytoplasmic characteristics. ‘“‘activated,”’ ‘‘stimulated,’” “‘sensitized,”’ “‘irritated,”’ or
There are occasional large granular lymphocytes and reactive ‘‘turned on.”’ Physicians are also justified in employing terms
cells of all types (Plate 37, Plate 38). The cytoplasm in some such as “‘reactive,” ‘‘transformed,”’ “‘transitional,’’ and
of the cells has a bubbly appearance. Vacuoles may be present. ‘‘rejuvenated.’’ The person responsible for the report ofthe
In rare instances, mitotic figures may be demonstrable. differential leukocyte count should not employ terms that
The bizarre lymphocytic, plasmocytic, and monocytic vari- involve etiology, response to antigenic stimuli, or function.
ants; blastoid cells; and mitotic figures that may be present
in association with the more-severe forms of infectious mono- T and B Lymphocytes (Fig 8, Fig 9). The first cells to
nucleosis may simulate the cytoplasmic changes observed in be identified as blood cells are large (macrocytic, megalocytic),
patients with lymphoblastic leukemia. Morphologically hemoglobin-containing nucleated red cells that appear in the
similar cells may be present in both diseases. The main yolk sac along with endothelial cells of primitive blood vessels
differences lie in the repetitious types of pathologic cells in during the early weeks of embryonic life. Hematopoiesis
leukemic states and the striking mixture of leukocytes of involving erythrocytes, granulocytes, monocytes, and mega-
various types in infectious mononucleosis. In the blood karyocytes occurs after the second month of fetal life. The
picture in infectious mononucleosis, there are—in addition hematopoietic organs that are next involved in the production
to an increase in small lymphocytes with normal morphologic of blood cells are the liver, spleen, bone marrow, thymus, and
characteristics—intermediate and large lymphocytes; lymph nodes in that order.
reactive lymphocytes of all types; as well as neutrophils, Morphologically undifferentiated progenitor cells (stem
monocytes, and occasional eosinophils and basophils. As a cells) that proliferate in fetal hematopoietic organs, including

19
 the marrow, are transported by the blood to various anatom- lymphocytes is the sheep erythrocyte rosette (E-rosette) test.
ical sites. Some of these migrant cells lodge in the thymus, This test is performed by incubating a solution rich in
an epithelial organ of the upper gastrointestinal tract. Stem lymphocytes with sheep erythrocytes which have an affinity
cells that come in contact with epithelial cells and grow and for, and cluster around, T cells. Approximately 70% to 80%
reproduce in the thymus have the anatomical characteristics of the lymphocytes in the peripheral blood of normal
of lymphocytes. Some of the thymus-related or thymus- individuals form E-rosettes.
dependent cells are seeded into lymph nodes, spleen, bone Research has revealed that undifferentiated mesenchymal
marrow, and other organs. cells (stem cells) originating in various fetal hematopoietic
During postnatal life, all types of blood cells, including organs migrate in the blood to the cloaca (bursa of Fabricus)
some of the lymphocytes and plasmocytes, are produced in of chickens where these progenitor cells come in contact with
the bone marrow. However, most of the lymphocytes and the epithelial cells of the hind gut. Cells having the morpho-
plasmocytes are derived from proliferating progenitor cells logic characteristics of lymphocytes proliferate in, and are
in the lymph nodes, tonsils, and thymus; and lymphoid tissues delivered from, the bursa into the blood. These cells are
in the spleen, the mucosal areas of the intestine, and the transported to, and transplanted in, lymph nodes and other
respiratory and genitourinary tracts, as well as other extra- lymphoid organs where they grow and multiply. Lymphocytes
medullary organs. that have come under the influence of epithelial cells of the
Thymus-related T lymphocytes are responsible for bursa of fowl are designated as “‘bursa-related”’ or B cells.
immunity ofthe cellular type (Fig 8). These cells function by The primary or central organ of the so-called B cells in
establishing direct contact with undesired foreign (nonself) mammals is not known.
cells and inhibiting the growth of, or killing, alien cells. In It is justified to employ the term ‘‘bursa equivalent’? when
cooperation with other cells of the immune system, T cells referring to B lymphocytes in man, but it is erroneous and
aid in the defense ofthe body against viral, fungal, and other inappropriate to identify B cells as ‘‘bone-marrow lympho-
infections; in the rejection of grafts; and in the inhibition of cytes’’ because the spelling of “bone marrow’’ happens to
growth or the destruction of body cells that have undergone start with a ‘‘B”’ or because the marrow is the place where
spontaneous and undesired mutations. T cells also provide some stem cells reside. Some of the stem cells that are the
the necessary help for B lymphocytes to differentiate into progenitor cells of thymus-related T cells during fetal life also
antibody-producing cells. In persons whose defense originate in the bone marrow. During postnatal life, most
mechanisms are depressed by total-body irradiation or by lymphocytes of all types (T, B, and null) are produced in
cytotoxic drugs and who receive bone marrow transfusions, lymphoid areas other than the bone marrow, and relatively
the T cells of the donor may predominate over those of the few are produced in lymphoid islands within marrow spaces.
recipient, resulting in graft-vs-host (runt) disease. When Some lymphocytes of B lineage, after stimulation by an
organs are transplanted, the cytotoxic cells of the host attempt antigen, respond by transforming into cells with basophilic
to reject the graft. T cells also participate in delayed sensitivity cytoplasm and with blastoid nuclear chromatin patterns.
reactions. These plasmalike cells (proplasmocytic, plasmocytoid)
The most-readily available, least-expensive, and most- develop within a few days into functioning plasma cells. These
frequently employed procedure for the identification of T cells manufacture and secrete into the plasma various types

CENTRAL LYMPHOID TISSUES PERIPHERAL LYMPHOID TISSUES

CELL-
REACTIVE MEDIATED
THYMUS TEYIMPHOCY TE
T LYMPHOCYTE IMMUNITY,

STEM CELLS

BURSA HUMORAL
EQUIVALENT B LYMPHOCYTE ——2@ PLASMOCYTE —=—
IMMUNITY

Fig 8—Lymphocytic system and immunity.

20
of immunoglobulins. Immunoglobulins in body fluids are new marrow in the form of nodular tumorlike tissues usually
designated as “‘humoral antibodies.’’ The humoral immunity located in the costovertebral areas. In malignancies involving
that is provided by plasmocytes is in contrast to ‘‘cellular myeloid cells, the lymph nodes—as well as nonhematopoietic
immunity’’ provided by T lymphocytes. organs such as the kidney, brain, skin, and other areas—are
B lymphocytes may be identified by the reaction that is involved in the proliferative process. In lymphoid malig-
observed after a suspension of lymphocytes is combined with nancies, multiple organs, including the bone marrow, are
fluorescein-conjugated antiserum. With this method, using involved in the proliferative process.
fluorescent microscopy, it has been noted that 10% to 15% In all biological systems, there are regulatory factors or
of the circulating lymphocytes have surface-membrane forces that aid in production, growth, and development and
immunoglobulin and are B cells. factors that restrain and inhibit, thus making it possible to
establish equilibrium and to maintain life. Thymus-related
Additional Information. During recent years, there has lymphocytes help B cells, plasmocytes, and phagocytic cells
been an explosive and fantastic development of new instru- in fulfilling their immunological functions. Cells that assist
ments and complicated, sophisticated, and expensive are designated as ‘‘helpers”’ or “‘inducers.’’ Other T cells
technical procedures to determine the functional charac- down-regulate the activity of immune reactions and are known
teristics of lymphocytes and other blood cells. Lymphocytes as ‘suppressors’ or ‘“‘inhibitors.’’ Technical procedures with
of the T and B cell lineage are identified and their relative monoclonal antibodies have been developed that make it pos-
numbers estimated by panels of membrane markers to detect sible to determine the percentage of T cells that are helpers
specific antigen contained within the cytoplasm or attached and those that are suppressors (the so-called H/S ratio). It has
to the membranes of cells. Lymphocytes that do not reveal been stated that T lymphocytes that possess cytotoxic capa-
membrane characteristics of either T or B lymphocytes are bilities, those that provide helper activity, and those that
designated as “‘null cells.” suppress immunological reactions are different cells and that
Although opinions differ concerning the origin and the any given cell does not possess multiple capabilities.
relationship of various families of blood cells and the matur- Most leukocytes survive only a few hours or days after
ation sequence of blood cells, it is generally agreed that delivery into the circulating blood or tissues. Some lympho-
lymphocytes and plasmocytes are closely related cells; that cytes, especially T lymphocytes, have a prolonged life expec-
progenitor célls of plasma cells, as well as lymphocytes, reside tancy and may survive months or years, retaining their repro-
in lymphoid organs; and that these cells have morphologic ductive capacity and ability to participate in immune
characteristics and immunologic functions that are different reactions. It is not possible to determine the age of any given
from nonlymphoid blood cells (Fig 10). lymphocyte by its appearance in stained smears.
Under conditions in which there are increased demands Lymphocytes that have a long life-expectancy migrate from
for the proliferation of cellsin hematopoietic organs, the areas the blood stream between and through the endothelial cells
occupied by fat cells in the marrow are first replaced by of capillaries and venules and through the basement mem-
proliferating hemic cells. If the stimulus is great enough, branes ofblood vessels into the tissue spaces of lymph nodes.
production of blood cells may occur in the liver and spleen. These cells later traverse the lining cells of lymph vessels. Then
In some cases, the proliferation also involves the creation of they are transported by efferent lymph channels into the

PLURIPOTENT STEM CELL

IMMUNOBLAST

LYMPHOBLAST LYMPHOBLAST i> PLASMOBLAST

PROLYMPHOCYTE PROLYMPHOCYTE PROPLASMOCYTE

LYMPHOCYTE LYMPHOCYTE PLASMOCYTE

T CELLS BCELLS

Fig 9—Lymphocytic-plasmocytic systems.

21
thoracic duct. The thoracic duct empties into the right the capability of retaining a memory of this immunological
innominate vein. Continual recirculation of lymphocytes from experience. Such lymphocytes also possess the capability of
the blood into tissue spaces and back into the circulating transferring ‘‘immunological memory’’ to successive gener-
blood favors the exposure of lymphocytes to antigens, the ations of daughter cells. Descendants of previously challenged
dissemination of antibody proteins, and the contact ofeffector lymphocytes, when again confronted by antigens of the same
cells with pathogenic organisms and with undesired cells. It type ata later date, respond more rapidly and more effectively
is possible and probable that lymphocytes, in the process of to the later challenge than at the time of the original contact.
passage through endothelial cells (emperipolesis) and through It is not possible on the basis of morphologic characteristics
narrow reticular spaces, continually lose portions of their of lymphocytes to differentiate T cells, B cells, and null cells,
membranes and cytoplasm, thus accounting for the paucity or to determine which cells are helpers or suppressors, and
of the cytoplasm in small lymphocytes. which cells have the potential to evolve into killer cells or
Lymphocytes have the ability to pass between or through producers of immunoglobulins. The fact that the future
epithelial cells of the gastrointestinal tract and into the lumen functions of lymphocytes are not revealed by microscopic
of the gut. In so doing, they serve as a means of protection procedures in no way detracts from the valuable information
for the body against enteric microbial pathogens. that is revealed by simple, readily available, and affordable
Lymphocytes that have been in contact with antigens and procedures.
have responded by participating in immune reactions acquire

TEYMPROCYTE

LYMPHOID
=
=~
=
~=
=~
— a
=~
=e

™ PLASMOCYTE
HEMATOPOIETIC
STEM CELL
ERYTHROCYTE

NONLYMPHOID

MONOCYTE

THROMBOCYTE

Fig 10—Lineage of lymphoid and nonlymphoid cells.

Plasmocytes The immunoglobulins manufactured by plasma cells
(Plasma Cells) produce many striking morphologic variants. The protein-
aceous material is usually in the form of round, red globules
called ‘‘Russell bodies”’ or ‘‘eosinophilic globules” (Plate 46).
The globules do not always take the red stain but may be
colorless or reveal pastel colors of pink, blue, or green. The
| a morphologically identified as lymphocytes globules may fill the cytoplasm, giving the appearance of a
and plasmocytes help and control each other and, in collabor- bunch of grapes (grape, berry, or morula cells). The secretory
ation with phagocytic granulocytes and cells of the monocytic- bodies are usually perfectly round (Plate 47).
macrophage system, are essential in the defense ofthe body In some cells, the spherules are so numerous and so tightly
against bacteria, viruses, spirochetes, rickettsiae, fungi, packed that they assume hexagonal or honey-comb shapes.
protozoa, and animal parasites. Without these cells, survival In other cells, the fiery red color has a diffuse distribution,
would not be possible in a hostile and competitive biological producing cells called ‘‘flame cells’’ or ‘‘flaming plasmo-
world. The combined action of defensive cells also serves as cytes’’ (Plate 46). The red-staining material may appear as
a barrier to the growth of cells foreign to the body, to malig- granules, as pools at the margins, or as extrusions through
nant cells, to the destructive action of plant and animal the cell membrane (Plate 46, Plate 47). After the escape of
poisons, to toxic chemicals, and to other noxious agents. secretory products, the residual cytoplasmic stroma appears
Plasmocytes constitute approximately 1% of the nucleated tattered and torn. The proteinaceous material within the cyto-
cells of the normal bone marrow but are not seen in the periph- plasm may crystallize and produce elongated and pointed
eral blood smears ofhealthy adults. They may be present in structures which may be colorless or stain various shades of
the circulating blood of young children and in the blood of red to purple (Plate 46). Rarely, there may be secretory
patients with viral infections including exanthemas, herpes, globules of varying size and number in the nuclei (Plate 47).
viral hepatitis, and infectious mononucleosis. Plasmocytes
are also observed in those with serum sickness, allergic states,
chronic bacterial and fungal infections, toxoplasmosis, and
multiple myeloma (Fig 12). In plasmocytic leukemia, in occa-
sional auto-immune states, and in situations in which the
immune system is suddenly challenged by antigenic materials,
the plasmocytes may be markedly increased.
Mature plasma cells, when found in blood smears, vary in
size from 15 to 25 ym. They are usually round or oval with
smooth or slightly irregular margins. The cytoplasm is non-
granular and stains a dark blue. In addition the cytoplasm
has a brilliant translucency. This rich and velvety quality—
variously described as cornflower, larkspur, or pigeon blue—
is thought to be due to numerous relatively unstained mito-
chondria and to lightly stained or reddish secretory products
that allow the light to be transmitted through the cytoplasm
containing numerous dark-blue (basophilic) ribosomes. The
cytoplasm adjacent to the nucleus is relatively pale (peri-
nuclear clear zone). Fibrillar structures that take a blue stain
may be demonstrable (Plate 7, right column). In many plas-
mocytes, there are one or several vacuoles. There is no
evidence of phagocytosis of visible particles.
The nuclei of mature plasmocytes are relatively small, oval
or round, and eccentric. The nuclear chromatin is coarse and
lumpy.
In tissues fixed in formaldehyde or other fixatives and
perhaps poorly dehydrated in the process of staining, there
may be produced in the nuclei artifacts characterized by the
tendency of the chromatin to clump and to adhere to the
nuclear membrane, giving the vague visual impression of the
spokes of a wheel. In stained blood and marrow smears, aggre-
gates of chromatin are demonstrable in some mature cells,
but ‘‘cart wheels”’ are figments of the imagination. The use
of the phrase ‘‘cart-wheel nucleus”’ is a cliche copied from
older textbooks of pathology, and it should be discarded.
Most plasmocytes in bone marrow are fixed or semifixed
cells which are torn in the process of aspiration and appear
in marrow smears with irregular spiculate margins (Plate 46).
Plasmocytes in the marrow are often seen in groups clustered
around large nongranular or finely granular tissue cells (Fig
11). It is thought that the contact of plasmocytes with large
histiocytic cells is a manifestation of the immune response
in which antigenic material, processed by macrophages, is
transferred to the plasma cells which in turn will manufacture
immune globulins. Proliferating plasma cells in association
with malignancy of the plasmocytic system are not grouped Fig 11—Plasmocytes clustered around finely granular tissue
around large mesenchymal cells. cells.

23
 Plasmoblasts and Proplasmocytes. Blood cells Waldenstrom’s disease (malignant macroglobulinemia) is
designated as ‘‘plasmoblasts’’ are morphologically similar a type of malignancy in which there is a mixture ofB lympho-
to the blastoid cells of other families of cells in that they are cytes, plasmalike lymphocytes, and well-differentiated
larger than the cells they are destined to produce. The nuclei plasmocytes. These cells grow and multiply in multiple hema-
are relatively large in relation to the cytoplasm. The cytoplasm topoietic organs. The ratio of cells with morphologic char-
is blue and nongranular. The nucleus is round and stains acteristics of small lymphocytes and plasmocytes varies in
purplish-red. The chromatin strands are fine and linear. different patients. Macroglobulin and blood viscosity
Nucleoli are clearly visible (Plate 7). The least-mature increase. Rouleaux formation is marked.
plasmoblast variants are differentiated from stem cells by Plasmocytomas are plasma-cell malignancies which, during
association with other cells but cannot be differentiated from their initial stages, are limited to focal areas in the bone
stem cells on the basis of size, shape, color, and structure. The marrow or in extramedullary areas.
more-mature plasmoblasts are more basophilic than the Plasma-cell myelomas in their early stages are character-
earlier forms due to the development of RNA particles which ized by focal areas of proliferation in the bone marrow,
have an affinity for methylene blue. followed by a progressive extension of growth in marrow
Proplasmocytes and the most-mature plasma cells differ spaces. Plasmocytes in small numbers are liberated into the
from plasmoblasts in that the color of the cytoplasm is dark blood. The plasmocytes vary in their morphologic character-
blue, the juxtanuclear light areas are prominent, and the istics (Fig 12). Mitotic figures and cells with multiple nuclei
nuclei are eccentric. The nuclei of mature plasmocytes are are demonstrable. There is asynchronism between nuclei and
pachychromatic, and the nucleoli are absent. The structure cytoplasm. Strands of precipitated globulin may be demon-
of the nuclei in proplasmocytes is intermediate between that strable in extracellular spaces. Rouleaux formation is a
of plasmoblasts and plasmocytes. prominent feature.
Plasma-cell leukemia is a variant form of multiple myeloma
Malignancies involving Plasmocytes. Malignancies characterized by the presence in the blood of large numbers
involving the cells of B cell lineage that are characterized by of plasmocytic cells. Malignant plasmocytes are derived from
the proliferation of plasmocytes include Waldenstrom’s stem cells and not from cells that morphologically resemble
disease, plasmocytoma, multiple myeloma, and plasma-cell small lymphocytes (Fig 9, Fig 10, Fig 12).
leukemia.

Fig 12—Plasmocytes in bone marrow smears, multiple myeloma.

24
Erythrocytes and distinct. In the very earliest forms, the cytoplasm stains
alight blue, but in later and more frequently occurring forms,
there is a superimposed reddish tint, due to the presence of
hemoglobin, which imparts to the cytoplasm a peculiar dark
and royal-blue color which is quite similar to that seen in
certain plasmocytes (Plate 1D).
asin Mature erythrocytes are derived from
committed erythroid progenitor cells through a series of Prorubricyte. This cell is differentiated from the rubri-
mitotic divisions and maturation phases. Erythropoietin, a blast by the coarsening of the chromatin pattern and ill-
hormonal agent produced largely by the kidney, acts at the defined or absent nucleoli. The cytoplasm contains varying
stem-cell level to induce proliferation and differentiation of
amounts of hemoglobin which has a reddish tinge, but the
predominant color is blue (Plate 1D, Plate 8). Prorubricytes
erythrocytes. When anemia occurs and there is a change in
the concentration of hemoglobin in the blood, there is a are normally smaller than rubriblasts.
decrease in tissue oxygen within the kidney. Responding to
this, the kidney produces erythropoietin which stimulates Rubricyte. Rubricytes are smaller than prorubricytes, have
erythropoiesis and induces the erythroid stem cell to increase relatively more cytoplasm, and take varying mixtures of red
red-cell production, followed by increased blood oxygen- and blue stains. The nuclear chromatin is thickened and
carrying capacity and increased tissue oxygen. irregularly condensed, and nucleoli are no longer visible
(Plate 1D, Plate 8).
Erythropoiesis occurs in the marrow over a period of about
five days through successive morphologic alterations from Metarubricyte. The metarubricyte has a predominantly
the rubriblast to a metarubricyte followed by anonnucleated red cytoplasm and minimal amounts of residual blue. The
diffusely basophilic erythrocyte and later by a mature erythro- nucleus is relatively small and has a nonlinear clumped chrom-
cyte. During the early maturation period, mitochondria, Golgi atin structure or a solid blue-black degenerated nucleus (Plate
apparatus, and polyribosomes are developed. Genes related 1D, Plate 8). Nucleated red cells with fragmented or partially
to hemoglobin synthesis are activated, and in the cytoplasm extruded nuclei(Plate 18G) are classified as metarubricytes.
of the later developmental stages, there is increasing hemo- The nucleus is extruded from the metarubricyte in the
globin synthesis. Three or four mitotic divisions occur in the marrow, leaving a diffusely basophilic cell.
early phases, but in the late phase, the cells are not able
to divide. Diffusely Basophilic Erythrocyte. These cells have
The main functions of erythrocytes are to transport oxygen lost their nuclei but still maintain some of their bluish color
to the tissues and to return carbon dioxide to the lungs from (Plate 1, Plate 8) due to the presence of ribosomes (Plate 1D,
the tissues. This gaseous exchange within the erythrocyte is Plate 8). They are larger than mature red cells. Diffusely baso-
facilitated by the oxygen-carrying protein, hemoglobin. The philic cells, when stained with new methylene blue or other
presence of hemoglobin usually is not visible as a reddish color supravital dyes before they are fixed, reveal granulofil-
in normal nucleated red cells until the rubricyte stage. In amentous structures and are identified as “‘reticulocytes.”’
addition to hemoglobin, mature erythrocytes also contain The diffusely basophilic cell is released in one to two days from
enzymes for the production of energy and for maintenance the marrow and circulates in the peripheral blood and spleen
of hemoglobin in the reduced state. Another function of for one to two days before maturing into an erythrocyte.
erythrocytes is to maintain acid-base equilibrium.
Different terms are employed for red cells; synonyms in Erythrocyte. Normal erythrocytes are biconcave discs, 6
common use are given in Table 5. to 8 wm in diameter and 1.5 to 2.5 ym thick, which appear
in stained smears as circular objects with distinct and smooth
Rubriblast. The earliest cells of the erythrocytic sequence margins. The intensity of the stain in the central portion where
are similar to other undifferentiated cells or ‘‘blasts.”’ the cell is thinnest is less than at the thicker marginal area
Nucleoli are usually visible. The chromatin strands are linear (Plate 1D, Plate 8). In very thin coverslip preparations and

Table 5—Synonyms: Red Cells

Rubriblast Proerythroblast Pronormoblast
Prorubricyte Basophilic erythroblast Basophilic normoblast
Early erythroblast Early normoblast
Rubricyte Polychromatophilic erythroblast Polychromatophilic normoblast
Polychromatic erythroblast Polychromatic normoblast
Intermediate erythroblast Intermediate normoblast
Metarubricyte Orthochromatic erythroblast Orthochromatic normoblast
Acidophilic erythroblast Acidophilic normoblast
Normochromic erythroblast Late normoblast
Late erythroblast
Diffusely basophilic erythrocyte Polychromatophilic erythrocyte Reticulocyte
Polychromatic erythrocyte
Proerythrocyte
Reticulocyte
Erythrocyte Erythrocyte Erythrocyte

25
 Left column: Macrocytic Middle column: Normal Right column:.Microcytic,
erythrocytes (megalocytic, erythrocytic sequence hypochromic cells of type seen
megaloblastic) of the type seen in iron deficient states
in pernicious anemia and related
B,.-folic acid deficient states

Rubriblasts

Prorubricytes

Rubricytes

Metarubricytes

Diffusely basophilic
erythrocytes

Erythrocytes

PLATE 8—ERYTHROCYTIC SYSTEM

26
 PLATE 9—COMPARATIVE MORPHOLOGY:
PLASMOCYTES, LYMPHOCYTES, AND IMMATURE NUCLEATED RED CELLS

A Plasmocyte with C Lymphocyte with E Prorubricyte with

intense-blue cytoplasm, slightly indented reddish-blue
eccentric nucleus, clear nucleus and unevenly cytoplasm
zone, vacuoles, and stained bluish
irregular shape cytoplasm
Plasmocyte with D Lymphocyte with foamy F Rubricyte with
eccentric nucleus, cytoplasm and frayed polychromatophilia
foamy and fibrillar (hairlike) margins
reddish-blue cytoplasm

EN
 at the extreme ends of smears, the red cells are flattened out Prorubricytes do not have a bubbly cytoplasm or fibrillar
like pancakes and do not reveal their true biconcave shapes. structure, seldom contain vacuoles, and usually have smooth
Very thin areas of smears where the erythrocytes are of margins. They have less cytoplasm than plasmocytes, the
uniform thickness are favorable for the visualization and perinuclear clear zone is less striking, and the nuclei are not
identification of malarial parasites and other cytoplasmic eccentric (Plate 9).
objects but are unfavorable areas for the evaluation of hemo- Features which favor the diagnosis of the cell as a plasmo-
globin concentration. cyte are the relatively large amount of cytoplasm, the oval
shape, the eccentric nucleus, the relatively large light area
Nucleated Red Cells Clustered Around Phago- next to the nucleus, the globules and vacuoles, the fibrillar
cyte. Tissue phagocytes that have acquired iron from structure, and the frayed edges (Plate 9).
ingested red blood cells and erythrocyte fragments serve as Lymphocytes have a narrow rim of blue cytoplasm; the peri-
feeder or nursing cells to nucleated red cells that cluster nucléar clear zone is present, and the nucleus is not eccentric
around their margins (Fig 13). There is intimate intercellular (Plate 9). Red color of the cytoplasm occasionally seen in
contact between the satellite nucleated erythrocytes and the plasma cells and in immature nucleated red cells is not present.
macrophage, with the phagocyte supplying nutrients, such In many individual cells, the similarity between plasmo-
as ferritin, to the surrounding nucleated cells, a process cytes, prorubricytes, and lymphocytes is so close that differ-
similar to nursing. entiation cannot be made on morphologic grounds alone.
Often it is necessary to classify the atypical cell by association
Prorubricytes vs. Plasmocytes vs. Lymphocytes. with predominant cells or by arbitrarily placing it in the
Prorubricytes, plasmocytes and lymphocytes have in common column statistically most likely. As in any other problem in
around nucleus without lobulations and a blue, nongranular differential morphology, a thin smear, a critical stain, a good
cytoplasm (Plate 9). Plasmocytes and immature cells of the microscope, a bright light, and experience are essential.
erythrocytic series may have mixtures of red and blue in their
cytoplasm which gives them an intense royal-blue color. In Pathological Erythrocytes. The nucleated erythro-
iron-deficiency anemias, the rubricytes and metarubricytes cytes in marrow smears of patients with pernicious anemia
are deficient in hemoglobin, and the blue color of the cyto- and related B,2-folic acid deficiency diseases are larger than
plasm closely simulates that of lymphocytes. Lymphocytes as normal and demonstrate asynchronism between the nucleus
well as plasmocytes may have bubbly or foamy cytoplasm. and cytoplasm, with hemoglobin synthesized in advance of

Fig 13—Nucleated red cells clustered around a tissue phagocyte.

28
the maturation of nuclear characteristics (Plate 18, Plate 27). based mainly on the structure of the nucleus and not on the
The nuclei of the earliest cells reveal marked variation in size or color of the cytoplasm.
chromatin structure. Some nuclei have delicate and uniformly
distributed chromatin strands, while others may have lumpy Anisocytosis, Poikilocytosis, Anisochromia.
as well as coarse linear chromatin patterns with wide sepa- Marked anisocytosis, poikilocytosis, and hypochromia are
ration between chromatin and parachromatin. Occasionally, characteristic features of thalassemia major (Plate 20).
there are slightly stained areas in the nucleus which are Spherocytes are densely stained red cells lacking in central
relatively devoid of chromatin. Nucleoli are usually demon- pallor and with diameters less than normal-sized red cells
strable in the first and second stages of maturation. (Plate 19, Plate 20). Spherocytes are the characteristic
The amount of cytoplasm in relation to the nucleus is erythrocyte abnormality of hereditary spherocytosis. Similar
increased. The color of the cytoplasm of the immature cells cells may be seen in acquired immune hemolytic anemias, in
is intensely purplish-blue (Plate 18, Plate 27), making it patients who have been transfused, in hemolytic anemia due
difficult to differentiate the earliest stages. In some cells, small to oxidant drugs, and in patients with increased hemolysis
areas of reddish-staining hemoglobin shining through the secondary to a large spleen.
basophilia are visible in the cytoplasm. An ovalocyte or elliptocyte is an elongated cell with blunt
Increased numbers of mitotic figures in the immature ends (Plate 19, Plate 20). A few oval red cells may be observed
erythroid cells are observed (Plate 27). Aberrant chromosomal in normal individuals. Small numbers of ovalocytes are
fragments also may be present in the cytoplasm of cells in observed in iron deficiency, thalassemia, sickled hemoglob-
mitosis. Howell-Jolly bodies may be seen in the erythroid inopathies, and other anemias. Ovalocytes occur in increased
precursors. numbers in hereditary ovalocytosis. Oval cells vary from
Peripheral blood smears reveal variation in the size and slightly oval or egg-shaped to long pencillike forms.
shape of erythrocytes, with oval macrocytes and teardrop Macrocytic ovalocytes are typical of megaloblastic anemia.
erythrocytes predominating (Plate 20). The mean corpuscular Erythrocytes containing sickle-cell hemoglobin (Hb S)
volume is increased (more than 100 fL or pm?) due to the undergo shape alterations when deoxygenated in sealed moist
presence of numerous cells that are larger than normal. There preparations and in moist preparations of blood mixed with
are also microcytes and irregularly shaped cells that are reducing agents such as sodium metabisulfite. The soluble
smaller than normal. Diffusely basophilic cells are present. sickle-cell hemoglobin when deoxygenated becomes insoluble
Other erythrocyte variants include macrocytic nucleated red and polymerizes in the form of elongated and pointed crystal-
cells with full hemoglobin component (Plate 18, Plate 27), like structures. These linear polymers distort the elastic
Howell-Jolly bodies (Plate 18, Plate 27), nucleated red cells membrane, producing multipointed, fanlike shapes (Plate 23).
demonstrating karyorrhexis (Plate 18, Plate 27), and Cabot Cells assuming this shape are capable of immediately revert-
rings (Plate 18, Plate 27, Fig 16). ing to the disc shape when reoxygenated. Such cells are known
Immature nucleated erythrocytes observed in anemias due as reversible sickle cells.
to chronic blood loss or to nutritional deficiencies, such as Erythrocytes that are identified as sickle cells in air-
iron deficiency or in various types of thalassemia are smaller exposed blood smears have undergone transformation over
than normal, have a decreased amount of hemoglobin in their an extended portion oftime, causing their membranes to lose
cytoplasm, and tend to have a relative increase in cytoplasmic their elasticity and become permanently sickled. These cells
basophilia in contrast to normal nucleated red cells. In severe are called irreversible sickle cells. Sickled red cells (drepan-
iron deficiency, the small nucleated red cells have scanty blue- ocytes, meniscocytes) are thin, elongated erythrocytes with
staining cytoplasm which has ragged edges. These small a point at each end; have no central pallor; and may have oat,
nucleated red cells observed in hemoglobin-deficient diseases crescent, ‘‘L,’’ “‘V,” or “‘S”’ shapes (Plate 19, Plate 21). Sickle
may be confused with small lymphocytes. In addition to the cells as a class are darker-than-normal red cells and may have
morphologic changes, there is an erythroid hyperplasia in the corrugated surfaces. In rare instances, there are rectangular
marrow which varies depending on the degree of anemia. cells. Schizocytes ofall types may be found. Sickled erythro-
The nucleated red cells in the smears of peripheral blood cytes are observed in the blood smears in sickle-cell anemia
and bone marrow of patients with malignancies involving the and Hb S-thalassemia and in small numbers in Hb SC disease.
erythrocytic cells, ie, erythroleukemia, reveal marked Irreversible sickled cells are not observed in air-exposed
variation in size, shape, color, and structure and show asynch- smears of the sickle-cell trait under normal conditions.
ronism in nuclear and cytoplasmic development. There is A target cell (codocyte) has a central area of hemoglobin
variability in nuclear chromatin, with delicate chromatin pigment surrounded by a relatively clear area and a peripheral
strands in some cells and a clumped pattern in other cells. rim of hemoglobin (Plate 19). There may be an extension of
There may be aberrant nuclear masses. Vacuoles of varying the peripheral rim of hemoglobin to the center of the cell.
size and shape appear often in the cytoplasm. There is intense Target cells are common in thalassemia, sickle-cell anemia,
erythroid hyperplasia of the marrow. The erythroblasts are Hb S-thalassemia, and other types of hemoglobinopathies.
distinctly abnormal, with giant cells, multinucleated forms, Microangiopathic hemolytic anemias (thrombotic throm-
nuclear budding, and nuclear fragmentation (Plate 44, Plate bocytopenic purpura, uremia with hypertension, sickle-cell
45). Mitotic figures are numerous and often bizarre. Periodic anemia with pulmonary emboli, diffuse intravascular coag-
acid Schiff stain gives a coarse red granular positivity in the ulation, heart-valve prosthesis, disseminated carcinoma, and
abnormal nucleated red cells, whereas normal nucleated ery- hemolytic uremic syndrome) are characterized by a variety
throcytes are negative or show a faint diffuse reddish color. of membrane-injured red cells including helmet, burr,
The various maturation stages of dysplastic nucleated red acanthocyte, spur, spiculated, fragmented, pinched, and
cells from patients with abnormalities involving erythro- triangular and cells with marginal achromia (Plate 19, Plate
cytes—such as pernicious anemia, microcytic hypochromic 21, Fig 14).
anemia, or erythroleukemia—should be categorized and There are marked changes in size, shape, and color in the
reported by the standard nomenclature recommended by the erythrocytes in patients with extensive burns and with heredi-
College of American Pathologists. The classification should tary pyropoikilocytosis (Plate 22). The red cells in hereditary
be ‘‘rubriblasts,”’ ‘“‘prorubricytes,”’ “‘rubricytes,’’ and ‘‘meta- pyropoikilocytosis show striking fragmentation when heated
rubricytes,’’ followed by a description of the morphologic to 45 °C in contrast to normal red cells which fragment at a
abnormalities that are revealed. The identification should be higher temperature (49 °C).

29
 The size and shape changes observed in myelofibrosis are as revealed in Wright stain and the granulofilamentous net-
shown in Plate 22. work in supravital stain are related phenomena. Coarse baso-
philic stippling and increased reticulocytes are noted in lead
Erythrocyte Inclusions. Granulofilamentous material or other heavy-metal intoxication and thalassemia. Stippled
(Plate 24) is visible in erythrocytes in supravital stain without cells and increased reticulocytes also may be seen after treat-
preliminary fixation. The reticulated material is thought to ment for nutritional deficiencies and after the use of cytotoxic
consist of aggregated masses of RNA and possible degen- drugs.
erated mitochondria. Red cells containing this granular and Howell-Jolly bodies are spherical nuclear fragments
filamentous network are called reticulocytes. Most cells composed of DNA (Plate 18, Plate 27, Fig 15) which may be
identified as reticulocytes have lost their nuclei, but a rare observed in erythrocytes ona blood film stained with Wright
metarubricyte with granulofilamentous material may be stain or with asupravital stain. Usually only one Howell-Jolly
observed. body is seen ina red cell. Normally, these nuclear remnants
Reticulocytes ina supravital stain, such as new methylene are pitted from erythrocytes during passage through the
blue, correspond to the diffusely basophilic cells appearing spleen. Howell-Jolly bodies are found in megaloblastic
in Wright stain which contains methyl alcohol as a fixative anemia, sickle-cell anemia, other hemolytic anemias, and
(Fig 15). A count of reticulocytes indicates the physiologic hyposplenism and after splenectomy.
activity of the marrow. Normal blood contains less than 2%. Cabot rings (Plate 18, Plate 27, Fig 16) are usually seen in
An increase in reticulocytes is observed in hemolytic anemia the form of rings, but they also may appear as granules ina
and after treatment for nutritional deficiencies. Decreased linear array rather than as complete rings. A ring may occur
reticulocytes are seen in hypoplastic states. near the membrane, appearing to outline the cell, or make
Basophilic stippling in red cells represents aggregation of a figure-eight form. Rarely there may be more than one ring
ribosomes which stain deep blue with Wright stain. This per red cell. These structures are frequently observed in
precipitated RNA appears as granules of varying sizes which stippled red cells, and they may also reside in the cytoplasm
are distributed throughout the cell (Plate 24, Fig 15). Stippling of nucleated red cells.

Fig 14—Shape variations in erythrocytes due to membrane alterations.

30
 Cabot rings stain reddish-blue with Wright stain or blue Protozoan parasites: The presence of rings and ‘‘nothing-
in new methylene blue. The exact nature of Cabot rings is not but-rings’’ in thin smears and thick-drop preparations of
known, but they are thought to be a protein precipitation blood is the hallmark of Plasmodium falciparum infection
artifact (ie, a part of the mitotic spindle or a remnant of the (Plate 30). Erythrocytes may contain multiple rings, some of
nuclear membrane). Cabot rings are observed mainly in which are extremely small. Occasional ring forms protrude
megaloblastic anemia. from the margins oferythrocytes. Some of the ring forms have
Heinz bodies represent denatured hemoglobin and are seen double chromatin masses. Occasional parasites appear linear
as round, blue precipitates in erythrocytes in moist prepara- rather than spherical. Some of these elongated parasites
tions after incubation with acetylphenylhydrazine followed appear to be attached to the erythrocyte membrane. The
by staining with crystal violet (Plate 25, Fig 15). One to four erythrocytes that contain malarial parasites of P falciparum
Heinz bodies per cell are observed in most normal red cells. after the ring stage of development sequester in terminal
Five or more smaller Heinz bodies are noted in the majority vascular channels and are seldom demonstrable in smears of
of erythrocytes in glucose 6-phosphate dehydrogenase (G6PD) peripheral blood.
deficiency, unstable hemoglobinopathies such as Hb Ziirich, A malarial ring may be confused with a platelet. The chrom-
and other hereditary hemolytic anemias following the use of ophobic area is inside the malarial ring, whereas the platelet
oxidizing drugs. that overlies or is under the red cell indents the cytoplasm,
Siderotic granules (Plate 26, Fig 15) are composed of ferric and the light that is refracted around the granular platelet
iron and appear as dark-blue granules (called Pappenheimer is revealed as a halo (Plate 18).
bodies) in Wright stain and as bluish-green granules in Perls’ Other forms of the four malarial parasites are in Plate 29.
Prussian blue reaction for iron. Siderotic granules vary in size The erythrocytes in Pvivax and P ovale are larger than normal
and shape, are usually few in number and unevenly distrib- and contain Schiiffner’s granules. The erythrocytes in P
uted, and often occur near the periphery of the erythrocyte. malariae malaria and P falciparum are not enlarged.
Nonnucleated erythrocytes containing siderotic granules are Ring forms of Babesia resemble the malarial rings of P
named ‘‘siderocytes,’’ and nucleated erythrocytes with falciparum (Plate 30). There may be multiple rings within a
siderotic granules are ‘‘sideroblasts.’’ When siderotic cell. Most of the rings are intraerythrocytic, but some are
granules appear in the mitochondria around the nucleus, they extraerythrocytic. Groups of free parasites outside the red
are called ‘‘ringed sideroblasts”’ and are characteristic of cells may be seen. A red cell containing Babesia is not
sideroblastic anemia (Plate 26). Siderotic granules are enlarged nor is pigment present.
observed in erythrocytes in hemolytic anemia, sideroblastic Babesia organisms are transmitted by the bite of a tick, and
anemia, and hyposplenism and after splenectomy. they infect many types of wild and domestic animals. Rarely,

SUPRAVITAL WRIGHT'S
STAIN STAIN

RETICULUM RNA

BASOPHILIC
RNA
STIPPLING

HOWELL- DNA
JOLLY BODY

SIDEROTIC IRON
GRANULE

DENATURED
HEINZ BODY GLOBIN

Fig 15—Red blood cell inclusions.

31
 humans are infected with Babesia microti which parasitize blunt ends (Plate 21). One or more hemoglobin crystals may
rodents. Babesia also has been reported to be transmitted by form within the cell, often leaving a clear area apparently
transfusion. Babesiosis clinically resembles malaria in that lacking in hemoglobin. Target cells are prominent.
patients have fever, lethargy, malaise, sweating, muscle pain, Erythrocytes containing Hemoglobin SC crystals are elon-
and hemolytic anemia. The disease is more severe in gated and often curved and have blunt, rather than sharp,
splenectomized individuals. _ points. These crystals protrude the membrane in one or more
Hemoglobin crystals: The intraerythrocytic crystals of directions, and there is a chromophobic area between the
Hemoglobin C disease are dense-staining and elongated with darker ends. (Plate 21, Fig 17).

Fig 16—Cabot rings.

Fig 17—Hemoglobin SC crystals.

32
Megakaryocytes Promegakaryocyte. The promegakaryocyte differs from
and Thrombocytes the megakaryoblast in that there are bluish granules in the
cytoplasm adjacent to the nucleus. The nucleus in this second
stage of maturation has usually divided one or more times,
and the cell has increased in size. Often there are bluish cyto-
plasmic extensions with rounded contours which may have
a homogeneous or a bubbly appearance (Plate 10, Plate 11).
Cc ELLS OF THE MEGAKARYOCYTICSYSTEM are peculiar in that
One of the variants of the promegakaryocyte is a cell with
the nucleus undergoes multiple mitotic divisions without cyto-
one or more nuclei with granular cytoplasm adjacent to the
plasmic separation, thus producing giant polyploid cells (Plate
nucleus encircled by a collar of vacuolated cytoplasm and by
10, Plate 11). All the nuclei in a given cell undergo mitosis
a third and distinct marginal zone characterized by dark-blue
at the same time (Plate 11) producing two, four, eight, or—
and rounded cytoplasmic protrusions which stain unevenly
in rare instances— 16 or 32 nuclei. The multiple nuclei usually
and often contain small colorless globules (Plate 11).
remain attached to each other and are often superimposed,
giving a lobular appearance. The dividing nuclei maintain Megakaryocyte (Megakaryocyte without thrombocytes).
the distinct linear chromatin pattern of young cells while the Megakaryocytic cells in the third stage of maturation are large
cytoplasm undergoes maturation changes characterized by cells with relatively large amounts of cytoplasm, round shapes,
the development of granules and membranes, culminating even margins, and multiple nuclei. The chromatin pattern
in platelet differentiation and liberation. of the nucleus is linear and coarse with distinct spaces between
Well-defined platelet masses usually appear at the margins the chromatin strands. The cytoplasm contains numerous
of megakaryocytes in the four to eight nucleate stages of small, rather uniformly distributed granules which have a
development, but in some cells, platelets form in cells with reddish-blue hue (Plate 10). Light-staining areas may be
single or double nuclei. When the nuclei and the cytoplasm demonstrable.
are out of step with each other, it is recommended that the
identity of the individual cell be established by the character- Metamegakaryocyte (Megakaryocyte with thrombo-
istics of the cytoplasm rather than by the chromatin structure cytes). Megakaryocytic cells in the fourth stage of maturation
or the number of nuclei. This is a departure from the rule that are characterized by the aggregation of granular cytoplasmic
the structure of the nucleus is the most reliable criterion for material into masses which are separated from each other by
identification. relatively clear spaces (demarcation membranes or vesicles).
Intact megakaryocytes, fragments of megakaryocytes, and These units of granular cytoplasm tend to aggregate near the
naked nuclei are occasionally demonstrable in smears of periphery of the cell (Plate 10).
peripheral blood from patients with myeloproliferative Megakaryocytes in the more-advanced stages of matura-
diseases such as chronic myelocytic and megakaryocytic tion are slowly ameboid. They extend portions of their
leukemia and in leukemic myelofibrosis. They are seldom cytoplasm through the basement membranes and between
observed in peripheral blood smears of normal individuals. the endothelial cells of the sinusoids of the bone marrow. From
In bone marrow smears and in sections of marrow tissue from these cytoplasmic protrusions, the differentiated and
normal individuals, the megakaryocytes constitute one to four membrane-bound platelets separate and are swept into the
per 1,000 nucleated cells. Most of the megakaryocytic cells flowing blood stream. Other megakaryocytes escape into the
are in the third and fourth stages of maturation. vascular channels of the marrow and are transported by veins
to the lungs where they lodge in the terminal pulmonary arter-
Megakaryoblast. The megakaryoblast is a large, irregu- ioles and alveolar capillaries. From these sites, they continue
larly shaped cell with a single nucleus or with several round to differentiate and to liberate portions of their cytoplasm
or oval nuclei and with a blue, nongranular cytoplasm. There in the form of platelets (Plate 10). The naked nuclei disinte-
may be blunt pseudopods which stain various shades of blue grate or are phagocytized.
and which may contain multiple chromophobic globules
(Plate 10, Plate 11). Spongy ectoplasm of this type is often Thrombocyte (Platelet). Thrombocytes are fragments of
demonstrable in sarcoma and in other malignant cells but is cytoplasm of megakaryocytes. In spreads of blood from
not present or is inconspicuous in primitive cells of the normal individuals, the diameters ofindividual platelets vary
erythrocytic or leukocytic series of blood cells. The nuclear from | to 4 zm, but in various diseases, the size may range
chromatin strands in megakaryoblasts are distinct. Nucleoli from barely visible structures to masses larger than red cells
usually are demonstrable (Plate 10). or leukocytes (Plate 36, Plate 50). As a rule, thrombocytes have

: Table 6— Morphological Features of Cellsofthe Megakaryocytic Series :

STATE OF MATURATION CYTOPLASMIC GRANULES _ THROMBOCYTES CYTOPLASMIC TAGS __NUCLEAR CHARACTERISTICS

Absent Absent Present Single

Sea ae Fine chromatin structure
Nucleoli

Promegakaryocyte Few Absent Present Double

Megakaryocyte Numerous Absent Usually absent Two or more nuclei

Metamegakaryocyte Aggregated Present Absent Four or more nuclei

33
 PLATE 10—MEGAKARYOCYTIC SYSTEM
A Megakaryoblast with single oval nucleus,
D Metamegakaryocyte with multiple nuclei and
nucleoli, and bluish foamy marginal
with thrombocytes (platelets)
cytoplasmic structures
E Metamegakaryocyte nucleus with attached
B Promegakaryocyte with two nuclei, granular
blue cytoplasm, and marginal bubbly thrombocytes
cytoplasmic structures F Thrombocytes (platelets)
C Megakaryocyte with granular cytoplasm and
without discrete thrombocytes (platelets)

34
 PLATE 11—-MEGAKARYOCYTIC VARIANTS

A Megakaryoblast, in prophase C Promegakaryocyte or intermediate

B Promegakaryocyte with four nuclei, megakaryocyte with multiple attached nuclei,
beginning granule formation adjacent to nucleus, granular cytoplasm surrounded by a ring of coarsely
and blunt nongranular pseudopods vacuolated cytoplasm and outer marginal darker
4 blue zone, and no well-delineated thrombocytes
D Atypical promegakaryocyte with
asynchronism between cytoplasm and nuclei,
multiple attached superimposed nuclei, fine.
granules adjacent to nucleus, and nongranular
ectoplasm.

35
 multiple pointed filaments or tentaclelike protrusions (Plate increased number of nuclei (hyperlobulation). Small mega-
10). Round, oval, spindle, and discoid shapes with smooth karyocytes (micromegakaryocytes) may be demonstrable in
margins are also observed. The cytoplasm stains a light blue smears of bone marrow of patients with myelocytic and
and contains variable numbers of small, blue granules which myelocytic-monocytic leukemia and in blast crisis of chronic
tend to aggregate in the center (granulomere, chromomere) granulocytic leukemia. These cells usually have a single round
as contrasted with the marginal zone which is nongranular nucleus. The cytoplasm may contain fine bluish granules. As
(hyalomere). a rule, there are blunt marginal nongranular protrusions
Platelets tend to adhere to each other (Plate 2). Individual which vary in the intensity of their staining qualities (Plate
platelets and clumps of platelets are most numerous at the 51). Platelet differentiation may be seen in these cells.
distal (feather) ends of blood smears. In thin portions where In idiopathic thrombocytopenic purpura, there is a relative
the erythrocytes and leukocytes are well separated, the and absolute increase in naked nuclei and in the number of
number per oil-immersion field varies from seven to 25. The megakaryocytes with granular cytoplasm and smooth
number of platelets in the average oil-immersion field margins.
multiplied by 20,000 gives the approximate number per cubic The size and shape of platelets in thrombocytopenic states
millimeter. No report of ablood smear is complete unless the is variable (Plate 50). Giant platelets are demonstrable in the
platelet number is stated and morphological abnormalities blood of patients with the May-Hegglin syndrome (Plate 36),
are described. leukemic myelofibrosis (Plate 50), thrombasthenia (Plate 50),
Platelets may appear as satellites around the cytoplasm of and myeloproliferative diseases (Fig 19). Giant platelets also
neutrophils when the. blood smear is made with an anti- are increased after splenectomy.
coagulant, particularly ethylenediaminetetraacetic acid Some of the large platelets contain aggregates of granular
(EDTA) (Fig 18). and linear material (granulomere) which sharply contrast with
the nongranular peripheral areas (hyalomere) (Plate 50).
Round or oval granular areas which stain more darkly than
Morphological Abnormalities. The size of megakary- the other portions superficially resemble nuclei (Plate 50, Fig
ocytes is increased in association with a deficiency of B,, 19). These aggregates differ from nuclei in that their margins
and/or folic acid. Large megakaryocytes usually have an are irregular and there is an absence of nuclear membrane.

Fig 18—Photomicrograph of platelet satellitosis. Fig 19—Drawing of platelets; myelofibrosis.

36
 FIXED MAlee
TISSUE BLOOD
GEELS CELLS

STEM CELL

Fig 20—Fixed tissue cells and free blood cells originating

from totipotent stem cell.

37
 il TISSUE CELLS

i. ADDITION to the free blood cells of the peripheral blood Stained tissue sections of bone marrow supplement the
and their precursors in the bone marrow, there are various examination of marrow smears by revealing the degree of
types offixed tissue cells. These cells are relatively immobile cellularity and fibrosis and the relationship of marrow cells
and are attached to other cells or imbedded by their cyto- to fat, trabecular bone, and blood vessels. Tissue sections also
plasmic extensions in the ground substance of the marrow provide information about the number of megakaryocytes,
and entrapped within the network of reticular and collagen tissue basophils, and giant cells, as well as the presence or
fibers. They are aspirated with difficulty and are best seen absence of hemorrhage, degenerative and necrotic lesions,
in tissue sections. granulomas, and amyloid and malignant cells.

Stem Cells typical blasts. Fine differences in shades of blue, however,

are difficult to discern, are impossible to define, and vary
depending on the stain and the staining technique employed.
In the process of counting and reporting the percentage
Ss... CELLS are morphologically undifferentiated cells of nucleated cells of various types, it is recommended that
that are progenitors of blood and tissue cells of various types morphologically undifferentiated cells with round nuclei,
(Plate 13, Plate 14, Plate 54, Fig 20). Stem cells are capable delicate nuclear chromatin strands, nucleoli, and nongranular
of self-replication, thus making it possible to maintain blue cytoplasm be reported as “‘stem cells’’ if they are present
ancestral cells that are readily available to replace cells that in small numbers. On the other hand, if the anaplastic cells
are lost from, or destroyed in, the body. Some of the cells of are associated with large numbers of definitive cells and if
the stem-cell pool, after appropriate stimulation, produce cells transitional forms are readily demonstrable, the cells that are
with distinctive functional and anatomical characteristics. difficult to identify are categorized as blast cells of the clone
Stem cells are not demonstrable in the peripheral blood that is predominent. For example, in smears of blood or bone
of normal individuals. Stem cells are identified in blood marrow of patients with myelocytic leukemia, the undiffer-
smears only in association with malignancies involving the entiated cells are identified as “‘myeloblasts.’’ Undiffer-
blood-forming organs. The number of stem cells in bone entiated cells demonstrable in a patient with lymphocytic
marrow in the absence of myeloproliferative diseases is less leukemia are called “‘lymphoblasts,”’ etc. In marrow smears
than one per 1,000 nucleated cells. from normal individuals or from patients with diseases in
The size of stem cells is variable, depending on their nutri- which the diagnosis is not possible, cells with nonspecific
tion and their growth between mitotic divisions. The cells that anatomical features are reported as “‘stem cells”’ rather than
are identified and reported as stem cells are the larger forms ‘‘blasts.’’ In leukemic states in which all of the blood cells
(Plate 14). Small stem cells are likely to be mistakenly identi- are morphologically and functionally immature, the diagnosis
fied as lymphocytes. of “‘stem cell leukemia’’ is justified.
Since stem cells in the bone marrow are fixed tissue cells Nucleated cells that are identified in hematopoietic organs
that are mechanically traumatized in the process of aspira- as stem cells may be progenitors of fixed tissue cells as well
tion, these cells usually have irregular shapes, frayed margins, as of free blood cells (Fig 20). Totipotent cells that have the
and blunt cytoplasmic projections (Plate 14). capability of developing into hemic, as well as tissue, cells have
The nuclei of stem cells are round or oval. The chromatin been designated as ‘‘hemohistioblasts.’’ Stem cells that are
strands are fine and linear. The nuclear substance between presumed to be precursors of blood cells only have been called
the chromatin threads (parachromatin) is well defined. There “‘hemocytoblasts.’’ The term ‘‘immunoblast’’ has been em-
is no evidence of chromatin clumping. Several nucleoli which ployed by some to designate cells that are thought to be
stain light blue usually are demonstrable. destined to produce progeny that are immunologically
The cytoplasm of stem cells may contain a few indistinct competent. These terms relate to concepts and theories rather
purplish granules. There are no large and well-defined than to morphologic entities. It is not possible by looking at
granules. There is no evidence of phagocytic particles or a given anaplastic cell to predict the appearance or the
digestive vacuoles. The color of the cytoplasm is light blue. function of the daughter cells that will be produced by that
Stem cells as a class contain in their cytoplasm fewer RNA cell. Tissue cells with nonspecific structural characteristics
bodies than cells designated as ‘‘blasts.’’ Cells that are should be reported as ‘“‘unclassified’’ and should not be iden-
precursors of “‘blasts’’ therefore stain less-intensely blue than tified as ‘‘reticuloendothelial cells’ or as ‘‘reticulum cells.”’

38
 PLATE 12—TISSUE GRANULOCYTES
A Tissue basophil (mast cell) B Tissue eosinophil C Tissue neutrophil

PLATE 13—FIXED TISSUE CELLS

A Phagocytic histiocyte with vacuoles and C Tissue neutrophil with coarse nuclear chromatin
phagocytized malarial pigment structure, neutrophilic granules, and shaggy
B Stem cell with partial rupture of margins
nuclear membrane and blue
nongranular cytoplasm

39
 Tissue Granulocytes associated with pancytopenia and myelosclerosis. Mast cells
may proliferate as localized tumors (urticaria pigmentosa) or
as a systemic disease (systemic mastocytosis).
Tissue basophils and blood basophils are closely related
in their chemical characteristics and in their functions. Their
difference is mainly one of motility.

Te GRANULOCYTES ofthe basophilic, eosinophilic, and Blood Basophils vs Tissue Basophils. Opinions
neutrophilic types are derived from stem cells. Early tissue differ about the relationship ofactively motile blood basophils
granulocytes lack distinctive characteristics. Tissue granu- and basophils that reside as slowly ameboid or fixed cells in
locytes are thought to be end-stage cells that do not differ- connective-tissue areas of various organs. The granules of
entiate into mature and motile granulocytes (Fig 20). blood and tissue basophils have similar morphologic charac-
teristics. The granules in both types of basophils are water
Tissue Basophils (Mast cells, heparinocytes). Tissue soluble and are metachromatic. The granules in both types
basophils are fixed tissue cells that are traumatized in the of cells contain heparin and histamine.
process of aspiration and therefore often have jagged The heparin secreted by perivascular tissue cells and by
margins. Many of the cells have spindle shapes and oval blood basophils aids in preventing intravascular coagulation
nuclei. The size varies. As a rule, the diameters of the more- and in maintaining the fluidity of the blood. There usually
round tissue basophils are from two to four times those ofred is an associated hemorrhagic tendency in diseases charac-
cells in the same field. The nucleus is relatively small and is terized by an increase in basophilic cells in the bone marrow.
round or oval. The cytoplasm is filled with intensely stained Blood basophils as well as tissue basophils participate in
violet-blue granules. The granules are uniformly round and a similar manner in acute and in delayed allergic reactions.
are approximately the same size (0.1 to 0.3 pm). They After release of histamine, the manifestations include
frequently overlie the margins ofthe relatively pale nucleus increased vascular permeability, perivascular edema,
or may partially or completely obscure the nucleus (Plate 12A, increased secretion of fluid from mucous membranes, and
Fig 21). itching. A massive and systemic release of histamine from
Tissue basophils are widely scattered in various organs basophilic granules, as with the bites of wasps or the injection
including the bone marrow. They usually are not encountered of serum or a drug to which the individual is highly sensitive,
while performing a differential count of afew hundred cells may lead to bronchospasm, edema of the respiratory tract,
but may be relatively increased and conspicuous in conditions anaphylactic shock, and sudden death.

Fig 21— Tissue basophils.

40
Tissue Eosinophils. In smears of bone marrow, one occa- they tend to be parallel to each other and to the cytoplasmic
sionally sees large cells with elongate and tapering cyto- margins (Plate 12C).
plasmic extensions and containing typical red granules of the The large round or oval nucleus has a coarse chromatin
type seen in the eosinophils of the circulating blood. The structure with a distinct linear pattern. Nucleoli are usually
nuclei of such cells, instead of being indented or lobulated, conspicuous (Plate 12C).
resemble those of the other fixed tissue cells, being round or Tissue neutrophils (Ferrata cells) are increased in bone
oval and having well-defined reticular chromatin patterns and marrow smears in conditions in which there is proliferation
often nucleoli (Plate 12B, Fig 22). of neutrophilic cells. These cells may be prominent in bone
It is thought that tissue eosinophils are fixed tissue variants marrow smears in myelocytic and monomyelocytic leukemia
of the more motile eosinophils of the circulating blood. (Naegeli type of monocytic leukemia), in leukemic myelosis,
in pernicious anemia, and in conditions in which there is
Tissue Neutrophils (Ferrata cells). One of the cell types, injury to cells associated with maturation arrest and a neu-
which is encountered in small numbers (less than 1 %)in prac- tropenic state due to chemicals and cytotoxic agents. Tissue
tically every smear of normal bone marrow, is a cell which neutrophils may be demonstrable in the peripheral blood of
resembles the undifferentiated mesenchymal cell except for patients with myelocytic or monomyelocytic leukemia.
the fact that it contains varying numbers of neutrophilic Many hematologists have assumed, and hematology texts
granules. often have stated, that large neutrophilic granulocytes with
Tissue neutrophils are large with ample cytoplasm. In rare irregular shapes that are demonstrable in bone marrow
instances, one may find a round or oval variant with smooth smears and that are designated as ‘‘Ferrata cells’’ are
contours, but as a rule, the shape is bizarre, with a combi- squashed promyelocytes and myelocytes. It is true that
nation of blunt pseudopods and multipointed and nebulous degenerated and mashed immature neutrophils superficially
cytoplasmic streamers. These cells are readily indented by resemble tissue neutrophils, but this is not an indication that
adjacent cells or are squeezed in between them (Fig 23, Fig well-preserved tissue neutrophils are artifacts. The demon-
24). Often there are long and tenuous cytoplasmic extensions stration of mitotic figures in cells that have the cytoplasmic
which seem to wrap around other cells. These cells are not and nuclear characteristics of tissue neutrophils is proof that
phagocytic and seldom have vacuoles in the cytoplasm. these cells are not senile and degenerative variants.
The cytoplasm stains light blue and has a fine latticelike It is universally accepted that there are fixed tissue
structure (Plate 12C, Plate 13C, Plate 14D). Granules vary in basophils and tissue eosinophils (Plate 12), as well as free
number. The granules stain varying shades of red to blue, but basophils and eosinophils, tissue phagocytes, motile mono-
the majority take a brilliant red or reddish-purple stain. Many cytes and macrophages, and tissue plasmocytes. There also
of the granules tend to be arranged in chains. The beadlike are circulating plasmocytes. Thus it is reasonable to assume
aggregates extend into the cytoplasmic projections where that tissue neutrophils are not artifacts.

Fig 22— Tissue eosinophils.

A
 N. MYELOCYTE TISSUE NEUTROPHIL HAIRY CELL

Fig 23—Relationship of myelocyte, tissue neutrophil, and

hairy cell to surrounding cells.

Fig 24—Tissue neutrophils (Ferrata cells).

42
 PLATE 14—FIXED TISSUE CELLS

A,B Undifferentiated mesenchymal cell C Unclassified immature fixed tissue cell with
(hemohistioblast, stem cell) with irregular minimal granulation, fibrillar structure, and
shape, blue cytoplasm with no granules, cytoplasmic extensions
linear chromatin, and nucleoli D Tissue neutrophil with few granules

43
 PLATE 15—MACROPHAGES
A Phagocytic histiocyte with reticular cytoplasmic C Phagocytic histiocyte, fixed tissue type with
Structure, vacuoles, and phagocytized particles phagocytized hemosiderin in cytoplasm
B Phagocytic histiocyte (ameboid macrophage) D Ameboid phagocyte (wandering
with phagocytized erythrocytes and dark- tissue macrophage) with phagocytized particles
staining particles and vacuoles in cytoplasm

44
Macrophages necessary for the catabolism of ingested cells, lipids of various
(Tissue Phagocytes, types—depending on the type of enzyme that is lacking—
accumulate in the cytoplasm ofthe phagocytic cells. Diseases
Phagocytic Histiocytes) associated with the storage of greasy and waxy structures
(lipids) are designated as ‘‘lipid-storage diseases’’ or as
“‘lipoidoses.”’
B.... CELLS designated as ‘‘macrophages’’ are large There are numerous types of storage diseases. From a
mononuclear cells that are capable of phagocytizing partic- hematological point of view, Gaucher’s and Neimann-Pick’s
ulate matter. These cells, during postnatal life, originate in diseases are ofparticular interest because the fat-laden macro-
the bone marrow from progenitor cells designated as phages in these diseases are numerous and are readily demon-
‘“‘monoblasts.’’ After maturation in marrow spaces, mono- strable in bone marrow smears and tissue sections.
cytes escape into the blood where they function as phagocytic The cytoplasmic inclusions in the macrophages ofpatients
cells. Some ofthese motile cells squirm between endothelial- with Gaucher’s disease are glucocerebrosides. Gaucher cells
lining cells of terminal blood vessels and through basement (Plate 52, left) are large with irregular shapes. They usually
membranes ofvascular channels into perivascular connective- occur as grouped fixed tissue cells. The nuclei are round and
tissue spaces where their growth continues. Some ofthese cells relatively small. The chromatin strands are distinct. Multiple
attach to connective-tissue fibers and become fixed. Other nuclei may be demonstrable. The pale-blue cytoplasm is
macrophages fulfill their function as wandering tissue cells. stuffed with doubly refractile and membrane-bound tubular
Fixed tissue cells that have phagocytic properties and are structures ofvarying lengths. Cells that contain short tubules
known as ‘‘Kupffer cells’’ are interspersed with endothelial- have a finely granular ground-glass appearance. The most
lining cells in the sinusoids of the liver. Other tissue phago- characteristic cells have a linear or fibrillar appearance due
cytes are demonstrable in the spleen, lymph nodes, and bone to the presence of elongated and narrow lipid inclusions.
marrow and in small numbers in the connective-tissue spaces Some of the rodlike structures are bent and have tapered ends
of all other organs. (crescentric or sicklelike shapes). Chromophobic tubular
Macrophages, as the name implies, are large cells. The structures that overlie or underlie the nucleus may be demon-
diameters of these cells are two to four times those of strable. Apt descriptive terms that have been used include
neutrophils in the same microscopic fields. The more-motile ‘“‘wrinkled cellophane,’ “‘crumpled tissue paper,’ and
cells are usually elongated and reveal blunt pseudopods (Plate ‘crinkled silk.”
15). The more-fixed tissue phagocytes that are torn away from Lipid-laden macrophages with elongated chromophobic
their moorings at the time of aspiration have shaggy margins cytoplasmic inclusions may be demonstrable in small
and multiple tapering cytoplasmic protrusions. numbers in bone marrow of patients with diseases other than
The nuclei are relatively small in relation to the cytoplasm. Gaucher’s disease. These cells are designated as ‘‘pseudo-
They are round, oval, or slightly indented. The chromatin Gaucher cells.’ Gaucher-like cells may be demonstrable in
pattern is linear. Nucleoli often are demonstrable. the bone marrow of patients with chronic myeloid leukemia
The cytoplasm of macrophages stains light blue and has and in numerous other diseases. The inclusions that are
a fine reticular structure. There are numerous granules of present in non-Gaucher cells are explained by the fact that
varying sizes (Plate 15). Vacuoles are demonstrable in the dead cells are phagocytized at a rate faster than the lipids in
cytoplasm ofmost of the cells. Phagocytized objects that may these cells can be digested.
be revealed in digestive vacuoles include intact red cells (Plate Cytoplasmic lipid inclusions of the Neimann-Pick type are
15) and leukocytes, cell fragments, platelets, hemosiderin due to accumulations of sphingomyelin that cannot be
(Plate 15), bacteria, fungi (Plate 53, left), protozoa (Plate 53, degraded and disposed ofbecause there is a deficiency in the
right), and crystals. enzyme necessary for the breakdown and disposal. Neimann-
Mononuclear microphages (monocytes) as well as occa- Pick cells are large with relatively small round nuclei. The
sional mononuclear macrophages are demonstrable in all cytoplasm is filled with small chromophobic and spherical
types of body fluids including urine, sputum, saliva, tears, inclusions enclosed by blue-staining fibrils (Plate 52, right).
cerebrospinal fluid, and mucous secretions from the nose and The fat globules in Neimann-Pick cells differ from the glob-
facial sinuses. Phagocytic monocytic cells also are demon- ules of fat in lipocytes in the bone marrow of normal
strable in the secretions of the gastrointestinal and genital individuals in that they are uniformly small and spherical.
tracts, in serous and synovial fluids, and in transudates and The globules of normal cells, in contrast, vary in size and
exudates. The sputum ofpatients with congestive heart failure shape (Plate 16).
and stasis of blood in pulmonary vessels contains macro- Phagocytic cells that have a foamy or bubbly cytoplasm and
phages laden with hemosiderin (heart-failure cells). reticular stromal pattern are demonstrable as isolated or as
Mononuclear phagocytes of the tissue spaces acquire grouped cells in the bone marrow ofpatients with numerous
antigen from ingested microorganisms, from cells that are diseases. The presence of tissue cells with multiple small
foreign to the body, and from chemicals bound to proteins digestive vacuoles is a nonspecific manifestation of
that have antigenic properties. The acquired antigens are cytoplasmic overloading. The presence oflarge numbers of
processed in the macrophages. Templates of these antigenic cells with prominent chromophobic cytoplasmic inclusions
substances are transferred to lymphocytes and plasmocytes should alert the examiner to the possibility of lipoidoses in
that cluster around the margins of the central phagocytes (Fig which there is a gene-determined enzyme deficiency. The
11). After stimulation by antigenic material supplied by findings of large numbers of storage macrophages in the
central feeder cells, the satellite cells transform into cells that marrow of a patient with splenomegaly, hepatomegaly,
become immunologically effective. lymphadenopathy, pancytopenia, cerebral manifestations,
malaise, failure to thrive, or other untoward symptoms and
signs aid in the confirmation of a hereditary storage disease.
Lipid-Storage Diseases (Lipoidoses). Cells of the Phagocytic tissue cells that contain in the cytoplasm
monocyte-macrophage system phagocytize and digest cell prominent granules and fibrillar structures that are green,
fragments and degenerated and dead cells of all types. When greenish-blue, or dark blue are designated as ‘‘sea-blue
there are inherited deficiencies in the production of enzymes histiocytes.’’ The blue-staining structures are thought to be

45
 incompletely degraded pigments and cell membranes. Macro- Fat Cells
phages with striking blue colors may be a manifestation of
a benign condition in which there is a hereditary enzyme
deficiency. Usually, the presence of sea-blue histiocytes is an
eye-catching nonspecific morphological anomaly.

Phagocytic Histiocytic Malignancies. Malignancies F. CELLS are seldom seen in thin smears of bone marrow,
involving mesenchymal cells that are morphologically undif- for they are ruptured in the process of aspiration. When
ferentiated and those that are potentially or actively spread on aslide, the contained globules offat tend to escape
phagocytic constitute a large, complex, and overlapping and leave the stroma and cell membranes as unidentifiable
spectrum of diseases which have been given an infinite debris. In thicker portions of the marrow smears, individual
number of names. Variants which are characterized by the fat cells or groups offat cells can be seen, surrounded by other
demonstrable ability of some ofthe cells to phagocytize are marrow cells.
monocytic leukemia, histiocytic-monocytic leukemia, and Mature fat cells are large round cells, comparable in size
histiocytic medullary reticulosis (malignant reticuloendo- to megakaryocytes and osteoclasts (50 to 80 pm in diameter).
theliosis, malignant histiocytosis). The small round or oval nuclei are located eccentrically,
Another entity characterized by cells that have feeble presumably pushed to one side by the pressure of globules
phagocytic properties is “‘hairy cell leukemia’ (histiocytic of fat in the cytoplasm. The chromatin structure in many of
leukemia). Hairy cells have villous cytoplasmic marginal the nuclei is definite and linear. Often there is a globular body
extensions and veillike ruffles. The cytoplasmic protrusions in the nucleus thought to be fatty material in the process of
of these aggressive malignant cells tend to push neighboring manufacture (Plate 16, Fig 26).
cells away, leaving wide clear spaces between these cells and The globules offat in the cytoplasm are of varying size and
adjacent erythrocytes (Plate 42, Fig 23, Fig 25). The nuclei are chromophobic or stain a light blue or pink. The fat
of hairy cells are round or only slightly indented. The chrom- globules have smooth margins. The globules compress each
atin strands are uniformly dispersed, and the nucleoli are other, producing irregular shapes. The lipid masses are
indistinct. The cytoplasm stains various shades of blue and separated in compartments by cytoplasmic material which
reveals a delicate reticular pattern. In some ofthe cells, there
appears as delicate blue lines (Plate 16). The fixed character
are distinct reddish granules. Some of the cells contain
of the cells is revealed by multiple fibrils which extend
cytoplasmic vacuoles (Plate 42). Opinions differ about the
outward from the cell margins (Plate 16) and interlace with
origin of hairy cells. Membrane markers suggest that these
the fibers of fibrocytes and endothelial cells. The lipid
cells have features of B lymphocytes. From a morphologic
material in fat cells has an affinity for various Sudan dyes.
point ofview, these cells resemble phagocytic cells rather than
lymphocytes. Hairy cells react positively with acid phos- Mesenchymal cells which manufacture fat are to be
phatase stain which is not sensitive to tartaric acid. differentiated from secretory plasma cells with large
aggregates of proteinaceous material in their cytoplasm. The
secretory droplets in the grape or morula variants of plasma
cells are spherical rather than irregular in shape and appear
as perfect superimposed circles as if drawn by a small compass
(Plate 47). Cells producing fat are also to be differentiated
from cells which phagocytize fat, the so-called ‘‘lipid-laden”’
histiocytes or “‘lipophages.”’ In phagocytic histiocytes, the
lipid particles tend to be small, giving to the cytoplasm a
foamy or bubbly appearance.

Fig 25—Hairy cells. Fig 26—Fat cell.

46
 PLATE 16—FAT CELLS

Top: Fat cell with small round nucleus, linear Bottom: Fat cell showing cytoplasmic lipoid bodies
chromatin and globular body in nucleus, ample separated by reticular structures. Structures
cytoplasm with lipoid globules, wrinkled membrane, surrounding fat cells are mature erythrocytes.
reticular stroma, and fibrillar marginal structures

47
 Bone Cells a bubbly appearance. Within the cytoplasm, there is a
prominent round or oval zone which takes a lighter stain than
the rest of the cytoplasm. This area may be adjacent to the
nucleus but is usually away from the nucleus (Plate 17, Fig 27).
Osteoblasts morphologically resemble plasma cells, for
both have irregular shapes, pointed cytoplasmic protrusions,
G:: THAT ARE LOCATED in the Haversian canals of blue cytoplasm, eccentric nuclei, spherical bodies within the
compact bone are designated as ‘‘osteocytes.’’ The term cytoplasm, chromophobic areas, cytoplasmic fibrils, and
‘‘osteoblasts’’ is used to name cells that are responsible for vacuoles.
the formation, calcification, and maintenance oftrabeculae Osteoblasts as a class are larger than plasmocytes. The
and cancellous bone. The destruction and removal of bone relatively unstained zone of the plasmocyte is adjacent to the
is the function of cells identified as ‘‘osteoclasts.’’ nucleus and partially surrounds the nucleus as a collar,
whereas the clear zone of the osteoblast is often distinctly
Osteoblasts. An osteoblast is a large cell with ample cyto- separate from the nuclear margin and when adjacent to the
plasm and relatively small, round, and eccentrically placed nucleus does not surround or enclose the nucleus. The protein
nucleus (Plate 17). These cells may be traumatized in the secretions of plasma cells impart a reddish background color
process of aspiration and smearing and often have irregular which is not demonstrable in osteoblasts.
shapes and cytoplasmic streamers. The cells may have comet Osteoblasts in marrow smears often appear in groups or
or tadpole shapes. Thenucleus may be partially extruded or aggregates which may be misinterpreted as malignant cells.
may rest outside the cell, like a small round head on a round The margins ofcells in a malignant cluster are indistinct, and
body. The nuclear chromatin strands and the nuclear margins one cannot tell where one cell begins and the other ends.
are well-defined. Usually there is a distinct nucleolus which Malignant cells are crowded and distorted. The size of the
takes a predominantly blue color in contrast to purple-red cells and the color and structure of the nuclei tend to be quite
stain of the chromosomes. variable, whereas in osteoblasts the cells are more orderly and
The basic color of the cytoplasm is blue. Wavy fibrils are uniform. Light-staining areas in the cytoplasm away from the
often visible. Throughout the cytoplasm, there are small nucleus are characteristic of osteoblasts and are seldom
spherical bodies which are colorless and give to the cytoplasm demonstrable in malignant cells.

CHROMOPHOBIC AREA

AWAY FROM NUCLEUS NEAR NUCLEUS

OSTEOBLAST PLASMOCYTE

Fig 27—Osteoblast vs plasmocyte.

48
 PLATE 17—OSTEOBLASTS AND OSTEOCLAST

A Osteoblast with prominent light zone in C Osteoclast: Large multinucleated cell with
cytoplasm located away from nucleus uneven number of separated oval nuclei, blue
B Osteoblast with oval eccentric nucleus, granules, and frayed cytopiasmic margins
distinct linear chromatin and nucleolus, blue
bubbly cytoplasm with prominent light zone, and
fibrillar marginal structures

49
 Osteoclasts. The osteoclast is a very large, irregularly cytoplasm, irregular shapes, and multiple nuclei. The nuclei
shaped, and elongated cell with multiple round or oval nuclei of megakaryocytes are connected by strands or are super-
which are approximately the same size. The number ofnuclei imposed, whereas the nuclei of osteoclasts are usually
is quite variable. The nuclei are separate and are distributed separated and have no visible connections with each other
haphazardly within the cytoplasm (Plate 17, Fig 28). It is (Fig 29). The number of nuclei in megakaryocytes is even,
thought that the large number of separated nuclei within a whereas the number of nuclei in osteoclasts may be uneven.
given cell is due to the fusion of the cytoplasm of multiple Osteoclasts are usually demonstrable in areas where bone
osteoblasts into a single large cell (osteoclast). The nuclear is in the process of demineralization and absorption. It is
chromatin is usually linear, and nucleoli are often visible. The thought that osteoclasts synthesize and secrete enzymes that
abundant blue cytoplasm has a finely granular or ground-glass aid in dissolution of osteoid tissue and calcific bone.
appearance. In some cells, there may be distinct granules. In There is evidence that plasmocytes in the bone marrow of
thin smears, it is sometimes possible to demonstrate a ruffled patients with multiple myeloma and lymphoid leukemia
cytoplasmic fringe consisting of diaphanous veils, fingerlike produce an osteoclast-stimulating factor that helps to explain
cytoplasmic protrusions, and sacular invaginations. the development of the osteolytic bone lesions observed in
Osteoclasts and megakaryocytes are sometimes difficult to these conditions.
differentiate, for both may be very large with granular

Fig 28—Osteoclast.

50
Fibrocytes Endothelial Cells
(Fibroblasts)

deen are connective-tissue cells present in blood- Oak one sees in marrow smears fragments of
forming organs as well as in all other parts of the body. These small intact vascular channels, the lumens of which are
cells are responsible for the synthesis and secretion of bounded by elongated nongranular cells with oval nuclei.
polypeptides (trophocollagen) that aggregate (polymerize, Spindle or oval cells may be scraped from the lining of blood
crystallize) into long fibrils. These fibrils form bundles of vessels or from the heart chambers by the point of a needle
varying size with varied physical and staining characteristics. in the process ofcollecting blood. These cells are identified
They are identified as reticular, collagen, and elastic fibers. as endothelial cells by their organoid arrangement. Individual
In tissue sections and in cultures, mature fibrocytes are endothelial cells are not identifiable.
elongated and spindle-shaped cells with oval nuclei, non-
granular or finely granular cytoplasms, and multiple
branching cytoplasmic protrusions. These cells are not
capable of phagocytizing large particles. Fibrocytes are so
tightly bound by their intertwined cytoplasmic extensions,
by connective-tissue ground substance, and by fibers that they
are aspirated with difficulty. They are seldom seen or at least
not identified as fibrocytes in smears or imprints of
hematopoietic organs.
Although fibroblasts usually are not thought of as blood
cells, they are essential constituents of blood-forming organs.
After injury to marrow cells due to any cause, there is a
proliferation of fibrocytes, producing fibrosis (scar tissue).
Malignancies involving fibrous-tissue elements are known as
fibrosarcomas. When the malignant process involves fibro-
cytes as well as other types of bone marrow cells, the condition
is known as “‘leukemic myelosis’’ (leukemic myelofibrosis,
agnogenic myelocytic metaplasia). In Hodgkin’s disease,
there is a malignant proliferation of lymphocytes as well as
fibrocytes and Reed-Sternberg and other cells.

NUCLEUS

SEPARATED ATTACHED

OSTEOCLAST MEGAKARYOCYTE

Fig 29—Osteoclast vs megakaryocyte.

51
 PATHOLOGICAL ERYTHROCYTES

PLATE 18—PATHOLOGICAL ERYTHROCYTES

Macrocytic rubricyte with two nuclei F Atypical nucleated red cell with degenerated
Stippled macrocytic rubricyte with fragmentation nucleus and nuclear fragments (? stippling)
of nucleus (karyorrhexis) G Metarubricyte with partial extrusion of
Macrocytic prorubricyte with asynchronism portion of nucleus
between nuclear structure and cytoplasmic H Atypical stippled metarubricyte with
color Howell-Jolly body and Cabot rings
Macrocytic prorubricyte with nuclear fragments
Erythrocyte containing malarial ring
and asynchronism between nucleus and
cytoplasm Thrombocyte on erythrocyte
Macrocytic prorubricyte with thickening of Howell-Jolly bodies in erythrocytes
portions of nuclear chromatin (pyknosis) eS
(2 Cabot rings in erythrocytes

52
 Y

Normal (discocyte) Crenated (berry) Burr (echinocyte)

Target (codocyte) Spherocyte

¢
Oat

Sickled
(drepanocyte, meniscocyte)
hs

SC crystal
&
Ovalocyte Folded
(elliptocyte)

Marginal achromic Helmet Pinched (pinchered)

(blister)

Pointed (pear, Filamented Triangular

teardrop, dacryocyte)

9
Poikilospherocyte Acanthocyte
Schizocyte
(schistocyte)
(small, dark, irregular) (thorn, spur, spicule)

Crescent
Membranous ghost (semilunar) PLATE 19—SHAPES OF RED CELLS

53
 Iron Deficiency Anemia Normal Pernicious Anemia

Thalassemia Major Hereditary Spherocytosis Ovalocytosis

PLATE 20—ERYTHROCYTE MORPHOLOGY IN VARIOUS DISEASES AND SYNDROMES

54
 Gd
Sickle Cell Anemia Sickle Cell—Hemoglobin C Disease Homozygous C Disease

Thrombotic Chronic Nephritis Sickle Cell Anemia

Thrombocytopenic Purpura (With Hypertension) With Pulmonary Embolism

PLATE 21—ERYTHROCYTE MORPHOLOGY IN VARIOUS DISEASES AND SYNDROMES

55
 PLATE 22— SELECTED ERYTHROCYTES FROM PATIENTS WITH BURNS
HEREDITARY PYROPOIKILOCYTOSIS (CENTER), AND MYELOFIBROSIS (LEFT),
(RIGHT)

56
 PLATE 23— MOIST UNSTAINED PREPARATION OF BLOOD FROM A PATIENT
WITH SICKLE-CELL TRAIT, SHOWING REVERSIBLE ELONGATED MULTIPOINTED
RED CELLS AND CELLS WITH MARGINAL PROTRUSIONS

57
 PLATE 24—STIPPLED CELLS, DIFFUSELY BASOPHILIC ERYTHROCYTES, AND RETICULOC
YTES
A Selected stippled erythrocytes (punctate C Selected reticulocytes containing
basophilia) in a Wright-stained blood smear granulofilamentous structures in a smear
from a patient with lead poisoning. from blood mixed with new methylene blue
B Selected diffusely basophilic erythrocytes in a Stain. Diffusely basophilic cells and stippled
blood smear, Wright stain. red cells are revealed as reticulocytes in a
new methylene blue preparation.

58
 e@ @ e° ae
| BZ S
a e e°
@ . 6

“ge
S <° @
6
6 hy e ! e og

oe 6
“eae

6 %

g @ © .

PLATE 25—ERYTHROCYTES WITH HEINZ BODIES

Erythrocytes in a moist preparation after four-hour incubation

with acetylphenylhydrazine followed by staining with crystal
violet (x 2,500)

Left: Normal blood with one to four Heinz bodies in most Right: Erythrocytes from a patient with G-6PD deficiency.
erythrocytes. Majority of red cells have five or more Heinz bodies.

= wet,

ee

PLATE 26—SIDEROTIC GRANULES IN ERYTHROCYTES

Left: Wright stain showing a metarubricyte and multiple. Aight: Prussian blue stain for iron showing one nucleated red
nonnucleated erythrocytes with Pappenheimer bodies cell (ringed sideroblast) and multiple nonnucleated erythrocytes
(siderotic granules). The granules vary in number, size, containing blue-staining siderotic granules (siderocytes). The
shape, and color and are unevenly distributed. nucleus of a nucleated red cell stains red with safranin. (Howell-
Jolly bodies, Heinz bodies, and RNA bodies in stippled cells do
not give a blue color with the iron stain.) x 2,500

59
 PLATE 27—PERNICIOUS ANEMIA, BONE MARROW

Selected nucleated and nonnucleated red cellsin bone _

marrow smears of patients with untreated pernicious anemia.
There is asynchronism between nucleus and cytoplasm with
the nucleus less mature than the cytoplasm. Identification of
nucleated cells is based on chromatin configuration and not
on cytoplasmic coloration. Anisocytosis, poikilocytosis, and
anisochromia may be observed in nonnucleated erythrocytes.

> Macrocytic metarubricyte showing karyorrhexis and Pear-shaped erythrocyte

asynchronism
Macrocytic rubricyte
Macrocytic rubricyte with Howell-Jolly bodies Macrocytic metarubricyte with fragmentation and
Teardrop erythrocyte beginning nuclear extrusion
Macrocytic prorubricyte with immature nucleus and more-
OOD Macrocytic dysplastic nucleated red cell
mature cytoplasm Microcytic poikilocyte
Stippled red blood cell Macrocytic rubriblast of type observed in pernicious
Cabot ring in oval macrocyte anemia
Diffusely basophilic cell Macrocyte with Howell-Jolly bodies
Large lobulated neutrophil Mitotic figure
Metarubricyte showing karyorrhexis and Howell-Jolly Macrocytic metarubricyte with one Howell-Jolly body
bodies Oval macrocyte
Macrocytic rubriblast (megaloblast) with multiple nucleoli Macrocytic prorubricyte
Hypersegmented neutrophil SeLCIOTM
ZX
DMWO
Prorubricyte

60
PLATE 27—PERNICIOUS ANEMIA, BONE MARROW

61
 PLATE 28—MALARIAL PARASITES: PLASMODIUM VIVAX

Bone marrow, Wright stain. Two malarial schizonts and the stroma
of a ruptured schizont with recently released merozoites.

62
 Plasmodium Plasmodium Plasmodium Plasmodium
talciparum vivax malariae ovale

Early ring

Late ring

Early intermediate stage

Late intermediate stage

Presegmented

Segmented (schizont)

Macrogametocyte

Microgametocyte

PLATE 29—MALARIAL PARASITES

63
 PLATE 30—PROTOZOAN PARASITES
Left: Babesia, intracellular and extracellular parasites
Right: Plasmodium falciparum, ring forms

64
PATHOLOGICAL LEUKOCYTES
AND THROMBOCYTES

PLATE 31—PATHOLOGICAL LEUKOCYTES

Neutrophil with prominent dark-bluish granules F Degenerated (pyknotic) nucleus in a neutrophil

(toxic granules) with prominent granules
Neutrophil segmented with vacuoles, a sign of G Hypersegmented macrocytic neutrophil
degeneration (PA poly)
Neutrophil metamyelocyte with toxic granules Monocyte with phagocytized pyknotic nucleus
Degenerated neutrophil with pyknotic nuclei (Tart cell)
and nuclear fragment Segmented neutrophil with purple-staining
cytoplasmic mass from a patient with lupus
il Giant neutrophil with multiple nuclei (polyploid
=
LS)
Bes
fon}
neutrophil) erythematosus

65
 PLATE 32—SO-CALLED “LE CELLS” IN SMEARS FROM PATIENTS WITH LUPUS ERYTHEMATOSUS

A Segmented neutrophil with swelling of lobes and H, | Degenerative changes in nuclei of

early degenerative changes (pre-LE cell) phagocytic neutrophils which have engulfed
B Segmented neutrophil with early lytic changes in lysed nuclear masses (post-LE cell)
nucleus and vacuoles in cytoplasm (pre-LE cell)
C Swelling and degenerative changes in lobes of The diagnosis of lupus erythematosus should
segmented neutrophil (pre-LE cell) not be made on the basis of morphology alone
but on clinical abnormalities and combined
D Two neutrophilic leukocytes adjacent to lysed
laboratory tests. In deciding whether or not the
nuclear masses. (Large groups of neutrophils morphological changes are compatible with
around degenerated nuclear material are known the diagnosis of lupus erythematosus, one
as rosettes.)
should appraise the degenerative changes in
E, F,G Neutrophils which contain in their digestive the cells destined to be phagocytized (pre-LE
vacuoles phagocytized purple or reddish-purple cells), the degenerative changes in the nuclei
nuclear material from other leukocytes. Cells of phagocytes (post-LE cells), as well as the
having this morphology are designated as “LE neutrophils with phagocytized nuclear masses
cells.’ The structure of the phagocytized mass is in their cytoplasm (LE cells).
not completely smooth and homogeneous but is
characterized by light and darker areas with an
absence of distinct linear markings.

66
 PLATE 33—PELGER-HUET ANOMALY
This hereditary anomaly is characterized by hypolobulation of the nuclei of granulocytes. The
chromatin structure of the granulocytes with round or indented nucleus is that of mature cells. The
size, chromatin structure, and phagocytic function of these cells are normal.

A “Peanut’-shaped nucleus C Nucleus with closely approximated round

B Round nucleus lobes (pince-nez)
D Slightly indented nucleus

67
ates Ue,
STE.
ae

PLATE 34—ALDER’S ANOMALY

A Neutrophilic myelocyte D Neutrophilic segmented

B Neutrophilic metamyelocyte E Basophil
C Neutrophilic band F Eosinophil
 PLATE 35—CHEDIAK-HIGASHI ANOMALY
Leukocytes in smears of peripheral blood or of bone marrow from patients with Chédiak-Higashi
anomaly showing abnormal and giant lysosomes in the cytoplasm.

A Lymphocyte D Eosinophil
B Promyelocyte in mitosis E Basophil
C Promyelocyte F Neutrophil

Other variants not shown include giant chromophobic globules, very-dark granules in
neutrophils, elongated granules, crystallike bodies, and large anomalous granules in monocytes.

69
 PLATE 36—CELL TYPES FOUND IN A SMEAR FROM A PATIENT WITH MAY-HEGGLIN
ANOMALY
A Monocyte with light blue cytoplasmic masses of Cells were arbitrarily chosen to show
varying sizes and irregular shapes (Dohle bodies) characteristic abnormalities. The number of
B Segmented neutrophils with Dahle bodies thrombocytes and leukocytes is greater
C Basophil with Déhle body than occurs in a single oil-immersion field.
D Eosinophil with Dohle body Note variation in shape of erythrocytes with
E Abnormal thrombocytes crenated, blunt filamented forms and
spherocytes.

70
 PLATE 37—INFECTIOUS MONONUCLEOSIS
A Primitive plasmalike cell F Atypical monocyte
B, C Plasmalike cells with indented nuclei and G Large lymphocyte with azurophilic granules
early nuclear structure and scalloped borders (indented by red cells)
D Large reactive lymphocyte with unevenly H Large lymphocyte with prominent reddish
stained bluish cytoplasm (azurophilic) granules
E Large lymphocyte with vacuoles in cytoplasm | Atypical monocyte

71
 PLATE 38— REACTIVE LYMPHOCYTES
In this color plate the leukocytes other than lymphocytes have been left out. Selected
lymphocytes
reacting to antigenic stimuli and showing heterogeneous forms have been portrayed
in increased
numbers in order to reveal the marked variation in size and shape and in nucleus and
cytoplasmic
characteristics. Note large cells with prominent basophilic cytoplasm, granules in some
cells, and
indentation of some lymphocytes by red cells. Red cells and thrombocytes are normal.

72
 PLATE 39—LYMPHOCYTIC LEUKEMIA

Lymphoblast with nucleolus F Atypical lymphocyte with clumping of nuclear

Lymphoblast with prominent nucleoli chromatin, purplish-red nongranular cytoplasm
Prolymphocyte with indistinct nucleolus G Prolymphocyte with deep nuclear cleft
(? lymphoblast) H Lymphocyte with multiple nuclear lobulation
leh Prolymphocyte with intermediate chromatin
@\eass | Lymphocyte with nuclear fragment
structure and rippled appearance of cytoplasm J Smudge
Prolymphocyte with double nuclei with
immature nuclear chromatin

73
 PLATE 40—GRANULOCYTIC LEUKEMIA
Myeloblast with prominent nucleoli, well-defined F Atypical promyelocyte with fine and coarse
chromatin structure, deep-blue cytoplasm, and granules
no granules G Atypical large granulocyte (simulating
Atypical early cell with dark coarse nuclear monocyte) with indented nucleus, intermediate
chromatin structure and blunt vacuolated nuclear chromatin structure, nonspecific
pseudopods (probably a micro-megakaryoblast) granules, and relatively large amount of
Myeloblast with Auer rod in cytoplasm cytoplasm .
Atypical promyelocyte with occasional dark H Atypical immature neutrophil (? neutrophilic
granules tissue cell)
Atypical promyelocyte with prominent purple | Macrocytic polyploid neutrophil
granules

74
 PLATE 41—MONOCYTIC LEUKEMIA

Monoblast with prominent nucleoli, indented F Monocyte with deeply indented nucleus and
nucleus, and blunt pseudopods granular cytoplasm
Monoblast with prominent nucleoli G Monocyte with transparent folded nucleus,
Monocyte with phagocytized red cell : granules in cytoplasm
> Promonocyte with nuclear folds, foamy
we
Si@ H Monocyte with folded nucleus, linear chromatin,
cytoplasm distinct granules, and elongated shape
Promonocyte with two nuclear lobes, nucleoli, | Promonocyte with nucleoli and vacuoles in
prominent granules, and clear ectoplasm cytoplasm

®
 PLATE 42—HAIRY-CELL LEUKEMIA
Selected cells as seen in peripheral blood smears from a patient with hairy-
cell leukemia. These cells have veillike cytoplasmic extrusions and delicate
threadlike filaments. They tend to push neighboring cells away or aside,
leaving clear spaces around the hairy cell.
 PLATE 43—SEZARY SYNDROME

A Vacuolated atypical immature lymphocyte with Cc Atypical lymphocyte of intermediate size with
indented nucleus, fine swirled chromatin pattern, brainlike (cerebriform) convolutions and
and nucleoli granules
B Vacuolated atypical early lymphocyte with D Atypical lymphocyte with nuclear folds and
distinct chromatin strands blue cytoplasm.

Features sometimes seen and not shown

include nuclear clefts:and cytoplasmic
extensions.

46
 PLATE 44—NUCLEATED RED CELLS IN SMEAR OF PERIPHERAL BL
OOD FROM PATIENT WITH
ERYTHROLEUKEMIA (DI GUGLIELMO'S DISEASE)

78
PLATE 45—NUCLEATED RED CELLS IN SMEAR OF BONE MARROW FROM PATIENT WITH
ERYTHROLEUKEMIA (DI GUGLIELMO'S DISEASE)

Note variation in size, vacuolization, multiple nuclei, and nuclear fragmentation.

 PLATE 46— PATHOLOGICAL PLASMOCYTES
A Plasmocyte with red-staining globules in C Plasmocyte with nebulous cytoplasmic margin
cytoplasm (Russell bodies) and red-staining multiple globules, and pink-staining
p)

material in nucleus homogeneous secretory material

B Plasmocyte with eccentric nucleus and with D Proplasmocyte with three nuclei and reticular
red-staining crystalline bodies, red globules, cytoplasm
and reticulated cytoplasm
E Flame type of plasmocyte

80
 E
F

PLATE 47—PLASMOCYTE VARIANTS

A Plasmocyte showing reticular cytoplasmic ; C Plasmocyte with multiple globules and frayed
structure margin
B Plasmocyte with globular bodies in nucleus, D, E, F Plasmocytes with globular bodies
reticular cytoplasmic structure, shaggy
margins, and red secretions

81
 PLATE 48—PEROXIDASE STAIN (SATO AND SEKIYA)

The two upper cells are peroxidase negative (lymphocytes); the two
lower cells are peroxidase positive (granulocytes). The red cells are
laked and appear as shadow forms. This stain is of aid in
differentiating early cells of the myelocytic and monocytic systems
from cells of the lymphocytic system.

82
 PLATE 49—CYTOCHEMICAL STAINS

Periodic acid-Schiff (PAS) reaction for the Sudan Black B stain for the detection of lipids:
detection of intracellular glycogen: D Immature granulocyte showing positive
A PAS positive substance in cytoplasm of a reaction
lymphocyte from a patient with Sézary E Lymphocyte showing a negative reaction
syndrome
F Strongly positive reaction in a neutrophil
B Negative PAS reaction
C Strongly positive PAS reaction ina Leukocyte alkaline phosphatase stain:
segmented neutrophil G Faintly positive reaction in a neutrophil
H Negative reaction in a neutrophilic granulocyte
| Strongly positive reaction in a neutrophil

83
 IDIOPATHIC THROMBOCYTOPENIC MAY-HEGGLIN ANOMALY
PURPURA

LEUKEMIC MYELOFIBROSIS
THROMBASTHENIA

PLATE 50— PATHOLOGICAL THROMBOCYTES (x 2,000)

84
 PLATE 51—MICROMEGAKARYOCYTES

Variant forms of small megakaryocytes from a patient with blast crisis of chronic granulocytic
leukemia. Nuclei are usually single, but one cell has double nuclei. In some cells, bubbly cytoplasm
and variable formation of platelets are noted.

85
 ‘ee

PLATE 52—LIPID HISTIOCYTES

Gaucher's Disease Niemann-Pick Disease

PLATE 53— BLOOD PARASITES

Macrophage with phagocytized Macrophage with Leishmania donovani
Histoplasma capsulatum

86
INDEX

Acanthocyte (spur, thorn)............ P22), B10), BS, 4h, SD POAT Srvc ks seme aa teen te orks 53, 04, 60, 61
UE TS OUND INAL VES el) ayerie as SMa esdee SON gl 10, 68 pinched (pinchered)s o-e.0 gas cise ee oe 2). Say, DS
PGCHEOUMAUCE DOUY) eo oie.6 ac nwa Buco an 5 10, 74 potkilospherocyter.... ... 2 a8 <thie. udp ogee 53, 90, 96
[KOM MNO, coke ee SRO AD ear ao 253, 54
BAD ESTA nT ear Oe ec: 7, Meaty ei lo. Be: 31-32, 64 polychromatophilic (diffusely
Band (nonfilamented, nonsegmented, basophilic), tae eee tet. res. 08 iv, 1, 25, 26, 58, 90
Stalossctath)ieaye eon twee: Ne, s,s Uy ry (OLS, Coe) PYLOPOPKilOCyte oe rete vs as aes oa eons 29, 56
Basophil schistocyte (fragmented cell) ...... 29, 30, 53, 54, 55
Dio cme Be cee Sac. 1, 4, 5, 7, 11, 68, 69, 89 semilunar ‘body (crescent. body) @a.00.nee. opens 53
(SSIS «cubes o-Ste ART an ane ee eee esa OAs39, 40 sickled (drepanocyte, meniscocyte) ....29, 53, 55, 57
Basophilia in erythrocyte, SlderOtic Oramulesany suv oe ow ones six hyaaa 31, 59
CUUBIDINS 2 5 coe vie oe meen eee iv, 1, 25, 26, 58, 60, 90 Sperone wee no re toner eine 29, 53, 54, 55, 70
UAC HALE (StI DPLCH 2026 a5 < saaytelh couse Foo crepe 52, 98 stippled (punctate basophilic) ..30, 31, 52, 58, 60, 61
Blast cell (see stem cell) SLOMALGCYLC “16 sengks, se aae eheo e eee 53
Blood cell (see specific name) SV MOMS IMS OMe snd ke opeek ie ee 25
maturation (development)... .iv, 1, 2, 4, 20, 22, 25, 89 target(codocyitc)e «..5. eee Dh), ays, Hs, Sb SS
MOVIES) 6 Succes oes Bye ee Dol On 2os SoM O0MOl 69 Hochuo ko)Oks MRR e Cea. oye vob oF: 53, 60, 61
MNOMEN ClALUTC MeRnP ees! ect haa ho av pe ete Pgek: 4, 25 triangular seme ok ee eee PRS), AW), Gey, OS)
PRUGM CX PRMTOCVIESHMNG (0-6 ire x gues hos wos. peo 29, 56
Katrcelli(lipo cyte) ae-esanc sos ca eee eae 46, 47
Cabot ite Fee RR ee Pee Bd Ol 29) 30:31), 32, 52) 61 Ferrata cell (tissue neutrophil)........... 39, 41, 42, 43
Chediak-ligasint cells i) gp cctn. we aecaias aleads: 10, 69 Fibroeyte (fibroblast) 202 2.0. tn neo ol
Crescent (semiilubial) DOGY <ccccaceod so ae gece ava nts 53 Flamerxcelli(plasmocyte)...... .:....aMice aeeeee = 23,,00;,,01
Fragmented cell (schistocyte)......... 29, 30, 53, 54, 55
DiGuglielmo’s disease (see Leukemia, erythrocytic)
DSM OGY tect eck ahiccm wR seri tals Sear.) OO Gametocyte 5 aia in ook os eeeee 63
Drepanocyte (sickle cell) jisict cn. sepeveysen,s 29 1935-005. 1 Gauchermsedisease cel loins eee ee men ane 45, 86
Granules
PROCVEC etn eR Bs Sn. Sie Sa vine uated 2 29, 53, 54 AVAUIHO) QUIN sous Boa eue sa oy oud 6 Sy ie, WSs MO, WAG 71!
dma uneliial! walls. 5 dam Maden aoe ome iia ema a eee ol basophilicn. fa. 08° ee eee D> Ux LT, 68, 69,:89
Eosinophil (acidophil) ........ 1h 5 25 KO), Cates, SL, 70), GY, Cosmop nities. fa ee Zeros (5 OOS ORGY
(HES. eee o cede dia ecreretore toenene anon eee eee Oe 39, 41 generale. es. ..22s . .. hanes Reece ees Py UP
Eiinnocrte fr. 8S. 85, Pe oat. BoA 29-32, 52-64, 70 MOUICOVMNG osoanasssoobuebeoudce 2,10; 17, 60, 89
acanthocyte (spur, thorn) ......... 29, 30, 53, 54, 55 |}dG ee pM ROMER AM EMPAE DT core ch A G'S A owe 6 4, {9)
IQeTABio. 25 o stated nee meen acre mem Seon am ater 5Ya}, OS) SECONDARY Aide Se iida as eae he 25,6
VANIER: o.oo oe Gere ath Cet ence eee eee eee 94, 55 Sid erotics(iron-containin'®) seer een erie 31, 59
blister (marginal achromia)........... DA), 310), OB, OD) Grapeberry, morula).cell 2.54. ..e en eee 23, 81
USOC PYaynd cca See ek RRS hisccee 29, 30, 53, 55
oboe Dine 1M to. e eho was PALI UPS leayes pea a) Nsreg da(o)ol| ree ereRN art ers er meen cee py « 42, 46, 76
CQMOCNTE ALAL ZED) ors> ou 0.4 Baeateydnmtencee
tsBtogatt.s 29, 93 Heinze odyai te. tht. 28 a. Mic oy ot See ae aR Sil, SY
Ghemate dip earre wie at enerect 53, 54, 70 Helmipticell: Srv... sca cc eee eae a8 Bes Woe l= 35)
Crescent (Seni Unan) ete pee arr 53 Hemoglobins #29 ort. ds! petersae 32, 53, 59
crystals i, (HbS:)55, SC,.CC) ...... WD) 3, 58s, Ds 7 Hemoglobings i4s-< sei AM teenies are oe 29, 99
daeryocyte (teardrop) «ian memyem o> Tifa: 53, 60, 61 HemoclobinwSCe -fseelee Goiciruce sae 29 SZ 5000
diffusely basophilic. ..iv, 1, 25, 26, 31, 58, 60, 61, 90 Hemohistioblast (undifferentiated
PEMITOCVNG Beers Peels aie nse on,Ge te oa B 53 mesenchymal. stem cell) o. ties DOORS
SUMLICaE OVA) ctxt es, Sek. nes 2 eon ee 29, 53, 94 Heparinocyte (tissue basophil, mast cell)......... 39, 40
PQ mCHEe a Mee ese odie ks Sean asec saan ma, oh, Histiocyte (see also macrophage)
LOC CCUMER Ie Rte Wea 2k veh 3 lock ny ana Sees De, OD) Iv onicCIs(=) eeaerateeet
at einer oman, Scr mera: 45, 46, 86
fragmented (schistocyte).......... 1), 0), OB, S45 OS DIAROC Vey. gan chit Arete Be eo ke 44, 45
helimeteriremte ny catits leas Searsrercicterecrn: 22), a), S35 OS Histioeytosiswlipid sin. cden toons soe ae eae 45, 46, 86
Howell-Jolly body in.......... Ae), ail), ill, GPA, OO, Ol Histoplasma capsulatum <0. .<G 0m mice oe eee 86
TIVO CU OMMLG Mra a a. ot aig A oe een as 26, 29, 54 Howell-Jolly body 0... 4..-<s..5-. 29-30,;31, 52; 60461
macrocytic (megalocytic)............. 26, 54, 60, 61 Hyperlobulation (hypersegmentation) ...... 9, 60, 61, 65
Ta lavlagineww yer aes Sree BL, Be, BY, OW, O31, ©)
Membranousm Gage Metal eses aeee neeeT 30, 53, 56 Infectouspmononucleosismesn ene etre 1), Ye}, Zl
meniscocyte.(sickle cell)... ccs ees ox Si; Oo, Oe
MDICEOOV UNC eie ecrmnie antag feo.vse3s ieee 26, 29, 54 Juvenile (neutrophilic metamyelocyte) ............... 6
Normalimertayeasce eee iN ly Oy 2B, 2X0, Gia, GY, OU
OVSENOVAIOCVIC) rans cease hair seeks 29, 53, 54 11519 coral os,county eta iaetea Beam Macetcen incaches cre steno ars 10, 65, 66

87
 LAO DEO COPOKUR. <o00¢000000Ge00005000080
8006 86 Ostéoclasty.n ares heeee ee 46, 48, 49,
Leukemia
erythrocytic (DiGuglielmo’s disease) ...... Zo, (Ome PA poly (hyperlobulated neutrophil)..... 6, 9, 60,
Pranulocyticn myelocytic) meee rie reeietet 9, 36, 74 Pappenheimer body (siderocyte)..............--
hustiocytie)(hatry cell) 22-4. ean oie 42, 46, 76 Pelger-Huét-anomalyeir. 95 eae ore
lymphocytic geet ick cc Pee teens nes 10, 15, 73 Renodicuacideochitta( PA) istalier er eee eer
TMONOCY
LIC Maes caren tena nee Rafe rn 1), WA, WS Peroxidaserstainmesme fe eerie teen 1), WL. 15, 82
Leukocyte alkaline phosphatase stain .............. 83 Plasmoblastasasteiae ae eke eee il Ike}, All 24, 90
Lipocyte:(tat-cell) waters 2. oe iar eres ace 46, 47 Plasmocyte (plasma cell) .2... 242.4. Nl, A ts, Al, 23-24,
Mupusrerythematosusscellsnnne sen eee ar 10, 65, 66 27, 80, 81, 90
Lemplioblastats scent. eee one eae I, US, 1h, 733, 0 Plasmodiuine sree ails 62, 63
vinip nocyitem eee Ih, Gy, WW, ae, BT, 8), Wl, GY, CS, CO) Platelet (see thrombocyte)
dormant; (Small) ate ora crs oo er eee eee ace 15 Polychromatophilia (polychromasia,
lobulatronsini ey wee ener eee Bree ee een 73 diffuse basopmnlia)ey. 9:20.05 cnet LvaeZos
nuclearaclettainwemey areca eNe eee ne (ds, 1 Polyploidys csecey wanes tenet aero icin eeae eee 65, 74
MUO MATTEO, oo cagcoscnscpesnoepeuoox 73 Prolymphocyteos-5 9) cet ert ie ee a ly alte 21,73
plasmocytoid (plasmalike)o7% «7.50
van CH de Promegakaryoeyté ...0 5 <ssyasae nee 1, 33, 34, 39, 90
REACLIVE US eee test ah cake Mn ces he ee ee NO), 0, Promonocytel.. sah fan n- 255 eee 2 vSs 25969
lim eandian Den Ske Cee ee ds te eh so ae 19-22, 24 Promyelocyte (progranulocyte) ....1, 6, 7, 11, 69,
Proplasmocyte-<.5- aes ae eee I dey, PAI, WA
Macroneutrop
nile vit. acer. stee ee 9 ROW SMO sconscbcase Why Il, Ay, Hos YUL, 4, (il).
Macnopitac enenaneeen rare 12, 23, 28, 44, 45, 46 Prussian bitesreactioniensa tetera
Malarial parasites (plasmodia) ..... 31-32, 52, 62, 63, 64 Pyropoikilocytosis (hereditary) =. 7.2%"
sn ees
Marginal achromia (blister cell).......... PAS) AU), Gehs Oe
Miastacel(tissaes basophil) ieerr ee ete terres 39, 40 Reactive lymphocytes: 22.5. ss55 ese 19, LW
May-tleg plinvanomlaly aa. 6.53 nvsk oo cheenos 9, 36, 70 Reticulocyte-..c 24.5. 2ss7 se nets oe eee 29, 30, 31, 58
Megatary ovlasty sc. 8 te weal 1, 33, 34, 35, 90 Rubriblas teenie eer er eee iv, 25, 26, 60, 61, 90
Miecalkalyocyite mena sane lh, aah, BH, SS) SO) Gill Oly RUbricyte: street a Iie thy CAD A405 AAU, BHA, (0), 61, 90
Mecaloblastreastts ..0) 2a. kc Oe et eee 26 Russell body (eosinophilic globules).......... Ws. 80, 81
Mienscocyite (sicklercell) esas see ee ZI IS HOOMON|
Mesenchymal cell, undifferentiated Satellitosis' cnccasee oes teak eee ee
(hemohistioblast, stem cell)).........:....... 38, 39 Semilunar (crescent) body* =. 7". 2)ee
Metamegakaryocyte.:: (i504
dats tata: 1, 33, 34, 90 Stzary syndrome;-cells imp... see ee
Metamvyelocyte <2 22. <25.2-:: 1, 4, 6, 7, 8, 17, 65, 68, 89 Sickle cell (drepanocyte, meniscocyte) .29, 30, 53, D9, OF
Metanubricy testes iv, 1, 25, 26, 52, 59, 60, 61, 90 Sideroblast Aes. asc eee he. nee 31, 59
Mierome ga kary 0c ie ria sacle cet esr eee 36, 85 Sideroblast,-ringéd'ja.. 4-042 50%4 ey oe eee
IMtOSIS eerie os oe 2, 3, 19, 25, 35, 60, 61, 69 Siderocyte: a3 tee Nie aS aaa eee
Monoblast=eet ete eens he 1, 12, 18, 75, 89 Smudge (smudged cell). 223, 2 eee ee
Monocyte (large mononuclear) ...... 5), A NS, Wee hee Sphieroeyted ucts. sehen. 6 oot ae ee rae rates 29,
18, 70, 71, 75, 89 Stem cellsemrss se 1,2, 4, 6,020; 25593 1,300, 09s405
Monocytecys lymphocyte 22402 o 06 bans chs. Wh, Web WG Stippledred’*cell’?.. 2 evaaee. 5 eee 30, 31, 58
Miyecloblastgeee reece Serre arta sc tela 1, 6, 7, 74, 89 Suid anelac kes(air aee eee 1@), 1a.
Mvelotytomes el irre te. dn em 1, 6, 7, 8, 17, 42, 68, 89
Mivelo
ior Osis paieener
ee enna renee ne 30, 36, 56 Target cell (codocyte)e cman ee 2S OO
Tart:celll cee eee eee
Neutrophil Thrombocyte (platelet) 255. so. eee oe ly os
bandl(Staliies tal) sean eee 1, 4, 5, 6, 7, 8, 68, 89 abnormal (pathological) heer ee 70,
Dohleth odiesmints peers Sees eset AE 9, 70 satellitosis:.a., on. et eee ee
filamented (segmented) ....1, 4, 5, 6, 7, 8, 11, 83, 89 Tissue basophill(masticell) geese nae
hyperlobulated macrocytic (PA poly). .6, 9, 60, 61, 65 Tissueeosinophil..10.4 2...522 ee: ee oe ee ee
nonfilamented (nonsegmented, band) .1, 5, 6, 7, 8, 89 Tissue neutrophil (Ferrata cell) .......... 39, 41,
New methylene blie-stains ee.ie eee 30, 58 Toxie*granules 25.22). <3. oe on) ee 5s OD
Niemann-bickisdisease.cell ins e eee eee 45, 86 ‘Turkcell, as c2cc2 de i eee
Nomenclature 2.2) ete. ne eee ee 35 2 2D
Normialivalitescoccenctiye svn See ee ee ee ee ee 4
INormob lasts? epg walyaecl ap. Sees wy oO, eee 20
Nucleoli..... IV Leet ,00,07, 1215, 19, 25, 34,'38, 43; 49,
73, 74, 75, 77, 89

Osteoblast# wae .c tye cttech Aas, hac Aa 48, 49

88
PLATE 54

ORIGIN AND DEVELOPMENT

OF
BLOOD CELLS
(on following two pages)
 PLATE 54—ORIGIN AND DEVELOPMENT OF BLOOD CELLS Pluri-
potential
Stem Cell

Monoblast

Promonocyte

Neutrophilic band

Basophilic segmented Neutrophilic segmented Eosinophilic segmented Monocyte

 Rubriblast Lymphoblast Plasmoblast

Prorubricyte

Rubricyte Prolymphocyte Proplasmocyte

Megakaryocyte
without thrombocytes

Diffusely basophilic
erythrocyte

Metamegakaryocyte

» ¢
Me &
Pad
®
Thrombocytes Erythrocyte Lymphocyte Plasmocyte

91
 $1 (EHES
ISBN 0-12539-715-1
ABBOTT DIAGNOSTICS
A DIVISION OF ABBOTT LABORATORIES
5
Unk
©1996 ADbdott Laporatories S7aT S19 Rony TGS eee: